Coverage of diabetes complications screening in rural Eastern Cape, South Africa: A cross-sectional survey

Abstract

Background: There is a paucity of data on the coverage of diabetes mellitus (DM) complications screening in primary healthcare facilities in South Africa (SA). This study assesses the extent of screening for DM complications among individuals with type 2 DM attending primary health facilities in rural Eastern Cape (EC), SA.

Methods: The study adopted a descriptive, cross-sectional design and obtained data from 372 individuals with type 2 diabetes attending six selected primary healthcare centres (PHCs) in two EC districts. Demographic and clinical data were obtained through questionnaire-based interviews and reviews of medical records. We assessed the extent of screening for estimated glomerular filtration rate (eGFR), fasting lipogram, eye examination, foot examination and glycated hemoglobin (HbA1c) in the past year.

Results: Participants mean age was 62 (standard deviation [s.d.] ± 11) years, and their mean duration of diagnosis was 9 (s.d. ± 8) years. In the past year, HbA1c result was available for 71 (19.1%) of the participants; 60 (16.1%) had eGFR results, while only 33 (8.9%) had documented lipid results. In total, 52 (14.0%) had carried out eye examinations, while only 9 (2.3%) had undergone foot examinations in the past year. About two-thirds of the participants (59.9%) had not undergone any form of complication screening in the past year, and none had undergone the complete screening panel.

Conclusion: The coverage of screening for DM complications was low across all indicators. Studies to understand barriers to and facilitators of DM complications screening at PHCs are required. Also, interventions to improve diabetes complication screening in the region are needed and should target the primary healthcare providers.

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Page 1 of 6 Original Research
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South African Family Pracce
ISSN: (Online) 2078-6204, (Print) 2078-6190
Authors:
Eyitayo O. Owolabi1
Daniel T. Goon2
Anthony I. Ajayi3
Oladele V. Adeniyi4
Kathryn M. Chu1
Aliaons:
1Centre for Global Surgery,
Department of Global Health,
Faculty of Medicine and
Health Sciences, Stellenbosch
University, Cape Town,
South Africa
2Department of Public
Health, Faculty of Health
Sciences, University of Fort
Hare, East London,
South Africa
3Populaon Dynamics and
Sexual and Reproducve
Health Unit, African
Populaon and Health
Research Centre, Nairobi,
Kenya
4Department of Family
Medicine, Faculty of Health
Sciences, Walter Sisulu
University/Cecilia Makiwane
Hospital, East London,
South Africa
Corresponding author:
Eyitayo Owolabi,
owolabiomolara101@gmail.
com
Dates:
Received: 05 Nov. 2021
Accepted: 05 Mar. 2022
Published: 25 Apr. 2022
How to cite this arcle:
Owolabi EO, Goon DT, Ajayi
AI, Adeniyi OV, Chu KM.
Coverage of diabetes
complicaons screening in
rural Eastern Cape, South
Africa: A cross-seconal
survey. S Afr Fam Pract.
2022;64(1), a5447.
hps://doi.org/10.4102/
safp.v64i1.5447
Background
Diabetes mellitus (DM) is a serious public health concern associated with significant morbidity,
mortality and disability.1 In South Africa (SA), 12.8% of the adult population lives with diabetes,2
and a significant proportion of them have uncontrolled diabetes, compounded by the presence of
other comorbidities.3,4,5 Consequently, individuals are predisposed to microvascular and
macrovascular complications, resulting in a reduced quality of life, an increased risk of premature
mortality and increased healthcare expenditure.6,7
Treatment guidelines, including those of the Society of Endocrinology, Metabolism and Diabetes
of South Africa (SEMDSA) and the South African Primary Health Care guidelines, strongly
emphasise the need for regular screening for diabetes complications to improve treatment
outcomes.8,9 Specifically, in this study setting, individuals with type 2 DM are provided with a
monthly drug supply and are expected to visit the clinic periodically for drug refills and
assessments in the absence of urgent medical conditions. At each of these visits, it is recommended
that weight, body mass index for cardiovascular risk if appropriate, blood glucose and blood
pressure measurements be carried out during patients’ assessments by nurses or nursing assistants.
Also, screening for diabetic kidney disease should be performed at diagnosis and subsequently on
an annual basis for individuals with type 2 DM using the urine albumin-to-creatinine ratio and
estimated glomerular filtration rate (eGFR). Individuals with type 2 DM should be screened for
diabetic retinopathy at diagnosis and then annually, or in resource-limited areas every two years,
provided the blood glucose level is controlled. Likewise, foot examinations are recommended
annually or more frequently among those at risk of developing foot ulcers.8,9
Background: There is a paucity of data on the coverage of diabetes mellitus (DM) complications
screening in primary healthcare facilities in South Africa (SA). This study assesses the extent of
screening for DM complications among individuals with type 2 DM attending primary health
facilities in rural Eastern Cape (EC), SA.
Methods: The study adopted a descriptive, cross-sectional design and obtained data from
372 individuals with type 2 diabetes attending six selected primary healthcare centres (PHCs)
in two EC districts. Demographic and clinical data were obtained through questionnaire-based
interviews and reviews of medical records. We assessed the extent of screening for estimated
glomerular filtration rate (eGFR), fasting lipogram, eye examination, foot examination and
glycated hemoglobin (HbA1c) in the past year.
Results: Participants mean age was 62 (standard deviation [s.d.] ± 11) years, and their mean
duration of diagnosis was 9 (s.d. ± 8) years. In the past year, HbA1c result was available for 71
(19.1%) of the participants; 60 (16.1%) had eGFR results, while only 33 (8.9%) had documented
lipid results. In total, 52 (14.0%) had carried out eye examinations, while only 9 (2.3%) had
undergone foot examinations in the past year. About two-thirds of the participants (59.9%) had
not undergone any form of complication screening in the past year, and none had undergone
the complete screening panel.
Conclusion: The coverage of screening for DM complications was low across all indicators.
Studies to understand barriers to and facilitators of DM complications screening at PHCs are
required. Also, interventions to improve diabetes complication screening in the region are
needed and should target the primary healthcare providers.
Keywords: diabetes; primary healthcare; screening; diabetes-related complications;
South Africa.
Coverage of diabetes complicaons screening in rural
Eastern Cape, South Africa: A cross-seconal survey
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Copyright: © 2022. The Authors. Licensee: AOSIS. This work is licensed under the Creave Commons Aribuon License.

Page 2 of 6 Original Research
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The South African public healthcare system serves 84% of
the population,10 with 69% of those in the lowest socio-
economic quantile mainly using the primary healthcare
centres (PHCs).11 Many people living with diabetes and
other chronic illnesses are managed at the PHCs.12 The
primary healthcare providers play a central role in
implementing promotive and preventive aspects of
healthcare.12 The management of end-organ complications
from DM, such as chronic renal failure, retinopathy and foot
infections, may require specialised care, which is usually
found at the hospitals. If PHCs fail to conduct thorough
screenings and make prompt referrals when needed,8,13,14
individuals with complications will be missed, and
treatment will be delayed, resulting in increased healthcare
costs, poor prognosis and mortality.15 Therefore, it is
imperative to assess the extent of diabetes complications
screening at PHCs, where most people receive health care.
Regular screening of patients with diabetes to promptly
identify complications is also a marker of the quality of care
received at the PHCs.
The extent of screening for DM complications has been
assessed in three of the 11 provinces in SA4,5,16 but only one
of the studies was conducted at the PHC level.16 Webb et
al.16 reported that the fasting glucose test was conducted
for only 1.5% of the patients, reported HbA1c for 23% of
patients, lipogram or total cholesterol for 26%, while 21%
of the patients were assessed for kidney function using
serum creatinine levels and 60% of them were assessed
using the urine dipstick. They further reported that only
8% had had an eye assessment and 6% had had their foot
assessed in the preceding year. All these studies are now
over 6 years and may not reflect the current situation.
Also, there are no available data on the level of screening
for diabetes complications in the Eastern Cape (EC), one of
the poorest provinces in SA, with a high prevalence of
diabetes and poor glycaemic control level.3,17 Therefore,
this study aimed to assess the extent of screening for
diabetes-related complications among individuals with
type 2 diabetes at selected PHCs in the rural EC province,
SA. This information is vital for informing health policy
decisions and advocacy. In addition, findings could
provide necessary data for strengthening the health
system.
Methods
Study design and sengs
This descriptive, cross-sectional study was conducted among
individuals with type 2 diabetes in the EC province, SA. The
EC province was created in 1994, comprising the old Xhosa
‘homelands’ of the Transkei and Ciskei and part of the
Cape province. The EC province is one of the poorest
provinces in SA.18,19 The province comprises two metropolitan
municipalities: Buffalo City and the Nelson Mandela Bay
Metropolitan Municipalities, and six districts: Alfred Nzo,
Amathole, Chris Hani Joe Gqabi, OR Tambo and Sarah
Baartman.19
This was a sub-study of a larger study, which sought to
determine the effectiveness of an mHealth intervention that
aimed at improving glycaemic control, conducted between
July 2018 and April 2019.17 This study was conducted at two
purposively selected districts of the eight health districts in
EC province: Buffalo City Metropolitan Municipality and
Amathole District. Guidelines for the management of
diabetes are the same across all the primary healthcare
facilities in SA.8 In each of these health districts, three PHCs
were conveniently selected, bringing the total to six PHCs.
Primary health care in SA is provided through a nurse-based,
doctor-supported infrastructure of clinics and community
health centres (CHCs), available within 5 km of home for
more than 90% of the population and free at the point of use.
Clinics are smaller health facilities, staffed by nurses and with
sessional visiting doctors (usually 4 h – 8 h a week).
Community health centres are larger facilities that are staffed
by a multidisciplinary PHC team consisting of nurses, doctors,
pharmacists and allied health workers. Individuals with
diabetes are usually seen by nurses who assess their blood
glucose level and blood pressure and prescribe medications
following the treatment guidelines. Those with a poorly
controlled glycaemic status are seen by doctors for further
management. For urgent and more complicated cases,
patients may be referred directly to the nearest hospitals.
Sample and sampling technique
The sample size for this study was estimated based on the
23% reported rate of screening for HbA1c by Webb et al.16
using the formula:
n = z2 * p * (1- p)/e2, [Eqn 1]
where z = 1.96 for a confidence level (α) of 95%, p = proportion
(expressed as a decimal), e = margin of error.
Z = 1.96, p = 0.23, e = 0.45
n = 1.962 × 0.23 * (1–0.23)/0.0452 [Eqn 2]
n = 336.
The estimated sample size was 336, adjusted by 15% to
account for incomplete data.
All ambulatory DM individuals who met the eligibility
criteria and were willing to participate were recruited
consecutively at the selected clinics. Primary health care
centres with specific diabetes clinics were visited on
scheduled days, while those which run open clinics were
visited daily. Data collection was carried out for a minimum
of two weeks at each clinic.
Eligibility criteria
Participants were included if previously diagnosed with type
2 diabetes, aged ≥ 18 years, attending the outpatient clinics of
the selected PHCs, and if willing to participate. All those who
were critically ill were excluded from the study and directed
for acute care management.

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Data collecon
The primary investigator (EOO), who is a professional nurse,
conducted interviews and reviewed medical records of
patients. Socio-demographic variables included gender, age,
education level, marital status, average monthly income and
employment status. Clinical characteristics assessed were as
follows: type of diabetes, year of diagnosis, type of treatment
and comorbidity.
Data on screening for DM complications in the past
12 months were obtained through a review of medical
records. These included eGFR and dipstick urinalysis for
albumin to ascertain kidney function, fasting lipids, eye
examination for cataract and retinopathy, foot examination
for diabetic foot (infections, peripheral vascular disease and
neuropathy), and HbA1c for glycaemic status. Patient self-
reporting was used where information on non-laboratory-
based complication screening was absent in the medical
records. Specifically, patients were asked about eye and foot
examinations in the previous 12 months. Responses to these
questions were either ‘Yes’ or ‘No’. In addition, random
glucose checks were carried out during the interviews.
The data collection tool was piloted with 20 participants at
one of the clinics to determine its validity and feasibility and
was revised as necessary. The results from the pilot study
were excluded from the data analysis.
Ethical consideraons
The Research Ethics Committee of the University of Fort Hare
granted ethical approval (reference number: GOO171OWA01)
for this study. We also obtained approvals from the EC
Department of Health, the two selected health districts and
the clinic heads. After detailed information, written informed
consents were obtained from the participants before the
commencement of the study. Rights to anonymity and
confidentiality were ensured during and after the study,
and participants consented to referral for further care in case
of detection of abnormal findings.
Data analysis
After data capturing, data were checked for completeness and
accuracy. Prior to analysis, data on individuals with type 1
diabetes (n = 27) were excluded, and final analysis was
conducted on individuals with type 2 diabetes. Descriptive
statistics were used to describe the proportion of participants
who had undergone any or all of the complications screening.
Data were expressed as counts (frequency) and proportions
(%) for categorical variables, while mean values (±Standard
deviation [s.d.]) were used to summarise continuous variables.
Percentages were compared using the Chi-square (χ2) test.
A p-value of < 0.05 was considered statistically significant. All
statistical analyses were performed using IBM Statistical
Package for Social Science (SPSS) version 25 for Windows
(IBM Corps, Armonk, New York, United States [US]).
Results
There were 372 participants, including 306 (82.3%) females.
All were black Africans and 306 (82.3%) were unemployed.
The mean age was 62 (s.d. ± 11) years, and the mean duration
of DM diagnosis was 9 (s.d. ± 8) years. The mean monthly
income was R1857 (s.d. ± 1868) and ranged from R150.00 to
R18 000.00. About three-quarters of the participants used
only oral DM medication, that is, 295 (79.3%), while 47
(12.6%) used only insulin (Table 1).
The rates of screening for complications among the patients
in the past year are presented in Table 2. HbA1c screening
had been conducted for only 71 (19.1%) of the participants.
Also, 60 (16.1%) had undergone tests for kidney function.
Only eight (2.2%) patients had undergone a foot examination
in the past year.
Also, 223 (59.9%) of the participants had not undergone any
form of complication screening in the past year, and none
had the complete screening panel (Figure 1).
As shown in Table 3, HbA1c testing was significantly
associated with random blood glucose (RBG) levels and
health facility types. HbA1c testing was higher among
participants with RBG ≥ 10 mmol/L (22.8%) than among
those whose RBG was < 10 mmol/L (12.2%, p = 0.008). Also,
the rate of HbA1c testing among participants managed at
CHCs was higher (22.8%) than among those who were
managed at the clinics (12.6%, p = 0.010). We also found a
significant association between eGFR testing and RBG levels
(p = 0.046). The eGFR testing rate was higher among patients
with RBG ≥ 10 mmol/L (18.7%) than among those with RBG
< 10 mmol/L (11.5%). Likewise, eye screening was associated
with treatment type (p = 0.009). The rate of eye screening was
higher among those managed with both insulin and oral pills
(26.7%) than among those managed with insulin only (23.4%)
or oral pills only (11.2%).
Discussion
While South African national guidelines recommend annual
kidney, eye and foot screenings among individuals with type
2 DM for microvascular and macrovascular complications,
this study has demonstrated that the selected PHCs in the two
districts in a rural province fell short of this target. The efficacy
and cost-effectiveness of annual screenings in DM
complications prevention are well-documented.20,21 The health
and socio-economic impacts of DM complications are
enormous6,7,22, and the low extent of screening for these
complications in our setting is of great concern. With such a
low level of complications screening, many individuals with
DM may develop preventable complications, which may be
detected too late for possible interventions.23 Although we did
not explore the reasons for such low coverage of complications
screening in this setting, similar findings have been reported
in another SA province.16 Perhaps, the physical and human
resources required for such screenings are very limited in the
study settings. New models of healthcare such as mhealth

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may be considered to offer specialised screening services for
persons with type 2 diabetes. Also, some evidence-based
guideline adjustments may be required. For instance, eyes
examination every 1–2 years following one or more eye
examinations and for those with well-controlled diabetes may
be more feasible or cost-effective. Agardh et al.24 showed that
3-year retinal screening intervals can be recommended for
persons with type 2 diabetes and with no retinopathy.
Glycated hemoglobin is the gold standard measure for
glycaemic control, and routine biannual testing is
recommended for those with good glycaemic control.8,9
Also, HbA1c testing is required to assess patients’
management, design new treatment plans and evaluate
progress. For this reason, HbA1c testing is also recommended
every three months after every treatment change or in
uncontrolled DM. Yet, only 19.5% of the patients had
undergone HbA1c testing in this setting, indicating that
patients’ glycaemic status had been poorly monitored. As
such, blood glucose may deteriorate, without healthcare
workers’ knowledge, in patients whose levels were
previously under control, as well as in patients whose blood
glucose is currently uncontrolled. Without such testing,
those on new treatment regimens may also deteriorate
because of the lack of adequate monitoring.
It is critical to emphasise the low coverage of screening for
complications in individuals with type 2 DM as reflected by
surrogate markers of retinopathy, nephropathy, neuropathy
and others in this study. These findings reflect the quality of
services currently offered at the PHCs in the region, and
therefore, call for urgent action. The SEMDSA and the South
African Primary Health Care guidelines8,9 have provided
guidance on the frequency of screening for DM complications.
Health authorities should now focus on the effective
implementation of these evidence-based guidelines in order
to improve the quality of care and health outcomes in
individuals with DM in the region.
While this study did not measure barriers to routine DM
complication screening, several possible reasons such as
physical and human resource constraints may explain the
study findings.5 For instance, we found significantly higher
rates of HbA1c testing among those attending care at CHCs
than among those receiving care at the clinics. This may be
because CHCs have more healthcare providers, including
doctors, nurses and others, along with more infrastructural
resources. Training and delegation of community health
workers or lesser qualified care providers to conduct some
screenings may be one way forward. This has been shown to
be effective for DM retinopathy screening.25 While this is a
TABLE 1: Parcipants’ characteriscs.
Variables Frequency (n)Percentage (%)
Gender
Male 66 17.7
Female 306 82.3
Highest level of educaon
No formal educaon 92.4
Grade 1–7 148 39.9
Grade 8–12 195 52.6
Terary 82.2
Post-grad 11 3.0
Marital status
Never married 88 23.9
Married 170 46.2
Single mother 7 1.9
Divorced 16 4.3
Widowed 86 23.4
Cohabing 10.3
Employment status
Government employee 7 1.9
Non-government employee 13 3.5
Self-employed 10 2.7
Rered 36 9.7
Unemployed 306 82.3
Average monthly income (rand)
R0.00 – R1500.00 51 16.6
R1501.00 – R3000.00 236 76.9
More than R3000.00 20 6.5
Duraon of diabetes diagnosis (years)
10 or less 262 70.6
More than 10 109 29.4
Duraon of diabetes treatment (years)
10 or less 262 70.6
More than 10 109 29.4
Type of treatment
Oral pills 295 79.3
Insulin 47 12.6
Both 30 8.1
Fasng blood sugar (mmol/L)
< 10 131 35.2
≥ 10 241 64.8
Blood pressure (mmHg)
< 140/90 126 34.1
≥ 140/90 244 65.9
TABLE 2: Screening for complicaons among parcipants in the past 12 months.
Variable Yes No
N%n%
HBA1c 71 19.1 301 80.9
eGFR 60 16.1 312 83.9
Lipids 33 8.9 339 91.1
Eyes screening 52 14.0 320 86.0
Foot examinaon 82.2 364 97.8
Urine test 30 8.1 342 91.9
HBA1c, glycated hemoglobin; eGFR, esmated glomerular ltraon rate.
FIGURE 1: Number of screenings carried out.
59.9
20.4
13.2
4.6
1.6 0.3
0
10
Percent
20
30
40
50
60
70
012345

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plausible reason, it is important to ascertain specific reasons
for such a low level of screening in this setting to design
appropriate interventions.
Strengths and limitaons
The cross-sectional nature of this study and convenience
sampling are apparent limitations. The use of self-
reporting might also be associated with recall bias.
However, we mitigated this limitation through the review
of records to confirm the information given. Also, only a
few clinics were covered; thus, results may not be
generalisable to the entire province. Moreover, in some
instances, patient records lacked complete information
which might have impacted the accuracy of the results.
Despite these limitations, the methodological rigour of
verifying self-reported information with a thorough
perusal of all available records and laboratory results are
important strengths of this study. Also, the information
gathered will serve as a reference point for issues regarding
compliance to treatment guidelines for diabetes in the EC
province.
Conclusion
Screening for DM complications in rural South African
primary health clinics is very low. There is a need for
implementing measures to improve patient screening and
adherence to evidence-based guidelines for improved
diabetes care, management and outcomes in the setting.
South Africa operates a tiered public healthcare system. The
primary healthcare facilities are most accessible to the
majority of the population. Access to quality health care is
essential for promoting health care and improving health
outcomes. Therefore, it is critical for services such as prompt
screening for complications and proper disease management
to be available at this level of care. Future studies should
ascertain possible reasons for such a low level of screening
for complications in order to guide the development of
appropriate interventions.
Acknowledgements
The authors are grateful to all the patients who agreed to take
part in the study. They also appreciate the management and
staff of all the healthcare facilities that enabled the success of
this study.
Compeng interests
The authors declare that they have no financial or personal
relationships that may have inappropriately influenced them
in writing this article.
Authors’ contribuons
E.O.O., D.T.G. and A.I.A. conceptualised the study. E.O.O.
obtained and analysed the data with inputs from AIA and
K.M.C. E.O.O. drafted the initial manuscript. A.I.A., K.M.C.,
D.T.G. and O.V.A. made substantial contributions to the
manuscript review. All authors approved the final version of
the manuscript.
TABLE 3: Screening for complicaons straed by demographic and clinical variables.
Variable HbA1c test eGFR Lipids Eye screening Foot examinaon Urine tesng
n%n%n%n%n%n%
Level of educaon
Grade 7 and below 36 22.9 31 19.7 11 7.0 22 14.0 5 3.2 17 10.8
Grade 8 and above 35 16.4 29 13.6 22 10.3 30 14.0 31.4 13 6.1
Employment status
Employed 7 23.3 620.0 5 16.7 7 23.3 0 0.0 13.3
Unemployed 64 18.7 54 15.8 28 8.2 45 13.2 82.3 29 8.5
Average monthly income
0–1500 611.8 47.8 35.9 815.7 0 0.0 47.8
More than 1500 50 19.5 46 18.0 21 8.2 35 13.7 62.3 21 8.2
Type of treatment
Oral pills 53 18.0 47 15.9 26 8.8 33*11.2 5 1.7 22 7.5
Insulin 12 25.5 817.0 5 10.6 11 23.4 24.3 612.8
Both 6 20.0 5 16.7 26.7 826.7 13.3 26.7
Hypertension history
Yes 61 19. 2 54 17.0 30 9.4 48 15.1 82.5 29 9.1
No 10 18.5 611.1 35.6 47.4 0 0.0 11.9
Random blood glucose (mmol/L)
< 10 16 12.2*15 11.5*96.9 22 16.8 43.1 86.1
≥ 10 55 22.8 45 18.7 24 10.0 30 12.4 41.7 22 9.1
Health facility type
Primary health clinics 17 12.6*17 12.6 14 10.4 20 14.8 43.0 7 5.2
Community health clinics 54 22.8 43 18.1 19 8.0 32 13.5 41.7 23 9.7
Diabetes duraon
≤ 10 years 52 19.8 39 14.9 22 8.4 36 13.7 62.3 21 8.0
≥ 10 years 19 17.4 21 19.3 11 10.1 16 14.7 21.8 98.3
HBA1c, glycated hemoglobin; eGFR, esmated glomerular ltraon rate.
*, p-value < 0.05.

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Funding informaon
E.O.O. received a grant from the National Research
Foundation for her doctoral study, during which the project
was implemented.
Data availability
Data supporting the findings of this study are available from
the corresponding author, E.O.O.
Disclaimer
The views and opinions expressed in this article are those of
the authors and do not necessarily reflect the official policy or
position of any affiliated agency of the authors.
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