Abstract

Aims To determine diabetes patient's adherence to five self-care behaviours (diet, exercise; medication, self-monitoring of blood glucose [SMBG] and foot care) in low- and middle-income countries. Design Systematic review. Data sources We searched MEDLINE, CINAHL, PUBMED, SCOPUS, PsycINFO, EMBASE, Cochrane library and EMCARE for the period January 1990 - June 2017. Review Methods Title, abstract and full text screening were done according to eligibility criteria. A narrative synthesis of the literature was conducted. Results A total of 7,109 studies were identified of which 27 met the review eligibility criteria and were included. All the studies used self-report of adherence to diabetes self-care. Studies reported adherence rates in two major forms: (a) mean number of days participants performed a recommended dietary behaviour/activity during the past week; and (b) proportions of participants adhering to a recommended self-care behaviour. Mean number of days per week participants adhered to a self-care behaviour ranged from 2.34.6 days per week for diet, 5.5-6.8 days per week for medication, 1.8-5.7 days per week for exercise, 0.2-2.2 days per week for SMBG and 2.2-4.3 days per week for foot care. Adherence rates ranged from 29.9%-91.7% for diet, 26.0%-97.0% for medication taking, 26.7%-69.0% for exercise, 13.0%-79.9% for self-monitoring of blood glucose and 17.0%-77.4% for foot care. Conclusion Although most diabetes patients do not adhere to recommended self-care behaviours, adherence rates vary widely and were found to be high in some instances. Impact Health services in low- and middle-income countries should monitor adherence to diabetes self-care behaviours rather than assume adherence and resources should be invested in improving adherence to the self-care behaviours. Large-scale accurate monitoring of adherence to diabetes self-care behaviour is needed and consideration should be given to choice of measurement tool for such exercise.


Authors

Mogre, Victor;  Johnson, Natalie A.;  Tzelepis, Flora;  Shaw, Jonathan E.;  Paul, Christine

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  • pre-publication peer review (FINAL ROUND)
    Decision Letter
    2019/08/05

    05-Aug-2019

    Re: JAN-2019-0019.R2: A systematic review of adherence to diabetes self-care behaviours: evidence from low-and middle-income countries

    Dear Dr MOGRE,

    Thank you for sending us your paper which has been considered with care. I am pleased to inform you that your paper has now been accepted for publication in the Journal of Advanced Nursing. The average time to online publication of the final version is 5 weeks. However, please see the information below about Accepted Articles.

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  • pre-publication peer review (ROUND 2)
    Decision Letter
    2019/06/13

    13-Jun-2019

    Re: JAN-2019-0019.R1: A systematic review of adherence to diabetes self-care behaviours: evidence from low-and middle-income countries

    Dear Dr MOGRE,

    Thank you for sending us the above manuscript. It has been considered with care and the editor and reviewer comments are shown at the end of this email. As these comments indicate, the paper does need revision before we can consider it further, and I look forward to receiving your revised version as soon as possible, and no later than 14-Jul-2019. If this poses any problems, please contact me at jan@wiley.com.

    Please take care to ensure that your revised manuscript addresses all of the editor and reviewer comments. Please also see the sections on general points to remember and search engine optimisation (SEO) at the end of the email.

    EDITOR'S COMMENTS:

    REVIEWER COMMENTS:

    Reviewer: 1

    Comments to the Author
    The revision of the article adequately addresses the concerns that were previously raised. The statistical data analysis is sound and the findings and discussions suitably represent the analysis results.

    Reviewer: 2

    Comments to the Author
    Thank you for providing me with the opportunity to review this revised re-submitted paper. The authors are to be thanked for improving their paper in line with the comments of the reviewers. I suggest some further minor revisions to the manuscript. After these revisions are completed, I would be satisfied for the article to be accepted for publication.
    In the discussion - the authors should address in greater detail how limited access to support services is likely to influence diabetes knowledge and adherence to self-care behaviours in LMICs. Please include references providing descriptions of diabetes support service availability and accessibility in LMICs included in the review.
    In the discussion section regarding dietary adherence – please address issues of affordability of fruits/vegetables. Are there any relevant references with pertinent information that could be included on this topic?
    For the limitations section – please add sentences to describe any potential bias arising from a fair level of agreement (rather than high/very high) between reviewers (k=0.33).
    Please also comment on the fact that all the included studies were published after 2006 but review start period was 1990. What are the possible explanations for this?
    Minor changes
    Page 1 line 36 – spell out SMBG at first use.
    Page 1 line 49 – missing word
    Page 2 line 16 – missing word
    Adherence -Page 5 lines 16-21 – please provide page number and reference for WHO quotation.
    Study designs – replace set of brackets within brackets with square brackets.
    Results page 8 line29 – remove percentage, report exact number only (24 out of 27) due to small n. Also remove percentages throughout where they refer to sub-samples of the reviewed papers
    Remove blank page (page 9).
    Results Page 9 line 31 – please report the total adherence score possible for the mean score of 3.6.
    Page 12 line 49 – missing word or typo.
    Page 15 paragraph 2 – split into a third paragraph at line 45, at the start of sentence: Another important…

    To revise your manuscript, log on to ScholarOne Manuscripts: http://mc.manuscriptcentral.com/jan

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    • Your revised word count must not exceed 5000 words for the text, exclusive of the abstract, references, tables and figures.

    • Format the headings like this: main headings upper case, major sub-headings lower case, subsidiary sub-headings italics.

    • The international relevance of the topic should be indicated in the Introduction section of the paper.

    • The Conclusion section should not be a summary or repetition of previous content. This section should provide a discussion of the implications for practice or policy and recommendations for further work.

    • For Review and Discussion papers, provide the inclusive years of literature searched in both the abstract and the text (not the year(s) when the literature was searched).

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    I look forward to receiving your revised paper. Please do not hesitate to contact me at jan@wiley.com if there is anything in this letter that needs more explanation.

    Thank you choosing JAN for your paper.

    Yours sincerely,

    Professor Robyn Gallagher
    Editor
    Journal of Advanced Nursing

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    Reviewer report
    2019/05/23

    Thank you for providing me with the opportunity to review this revised re-submitted paper. The authors are to be thanked for improving their paper in line with the comments of the reviewers. I suggest some further minor revisions to the manuscript. After these revisions are completed, I would be satisfied for the article to be accepted for publication.
    In the discussion - the authors should address in greater detail how limited access to support services is likely to influence diabetes knowledge and adherence to self-care behaviours in LMICs. Please include references providing descriptions of diabetes support service availability and accessibility in LMICs included in the review.
    In the discussion section regarding dietary adherence – please address issues of affordability of fruits/vegetables. Are there any relevant references with pertinent information that could be included on this topic?
    For the limitations section – please add sentences to describe any potential bias arising from a fair level of agreement (rather than high/very high) between reviewers (k=0.33).
    Please also comment on the fact that all the included studies were published after 2006 but review start period was 1990. What are the possible explanations for this?
    Minor changes
    Page 1 line 36 – spell out SMBG at first use.
    Page 1 line 49 – missing word
    Page 2 line 16 – missing word
    Adherence -Page 5 lines 16-21 – please provide page number and reference for WHO quotation.
    Study designs – replace set of brackets within brackets with square brackets.
    Results page 8 line29 – remove percentage, report exact number only (24 out of 27) due to small n. Also remove percentages throughout where they refer to sub-samples of the reviewed papers
    Remove blank page (page 9).
    Results Page 9 line 31 – please report the total adherence score possible for the mean score of 3.6.
    Page 12 line 49 – missing word or typo.
    Page 15 paragraph 2 – split into a third paragraph at line 45, at the start of sentence: Another important…

    Reviewed by
    Cite this review
    Reviewer report
    2019/05/11

    The revision of the article adequately addresses the concerns that were previously raised. The statistical data analysis is sound and the findings and discussions suitably represent the analysis results.

    Reviewed by
    Cite this review
  • pre-publication peer review (ROUND 1)
    Decision Letter
    2019/04/08

    08-Apr-2019

    Re: JAN-2019-0019: A systematic review of adherence to diabetes self-care behaviours: evidence from low-and middle-income countries

    Dear Dr MOGRE,

    Thank you for sending us the above manuscript. It has been considered with care and the editor and reviewer comments are shown at the end of this email. As these comments indicate, the paper does need revision before we can consider it further, and I look forward to receiving your revised version as soon as possible, and no later than 09-May-2019. If this poses any problems, please contact me at jan@wiley.com.

    Please take care to ensure that your revised manuscript addresses all of the editor and reviewer comments. Please also see the sections on general points to remember and search engine optimisation (SEO) at the end of the email.

    EDITOR'S COMMENTS: Please pay careful attention to points raised by reviewer 3 regarding the implications for self-care in resource poor settings and what is reasonable to implement. Please address the issue of sensitivity analyses.

    REVIEWER COMMENTS:

    Reviewer: 1

    Comments to the Author
    • This is a robust systematic review and well written paper. The appropriate systematic review reporting guidelines (PRISMA) and quality assessment tool (NHLBI Quality assessment tool) have been used. The systematic review was also registered with PROSPERO. The methods are applicable and the reporting of results is clear and concise.
    • My main concerns with the paper are the lack of information about the reasons for excluding the 4008 articles excluded based on titles and abstracts. The authors need to provide summary information and some examples to describe the decision-making process.
    • The paper also requires the number of papers identified in each separate database (either in the results text or Figure 1 and the number of papers excluded from each database after scanning the titles and abstracts.
    • To assist the reader to form an overview of the evidence, where possible and appropriate, report median adherence rates for each behaviour from the included studies. E.g. dietary adherence rates ranged from 29.9% to 91.7%. What was the median dietary adherence found through synthesising the evidence? It may also help to report a mean or median (where appropriate) across the relevant studies for mean number of days participants adhered to diet.
    • The authors should not report percentages for small numbers (e.g. as reported in paper - 59%, n=16). Report either n=16 or 16 out of 27.
    Abstract
    • Foot care is included erroneously in the brackets after self-monitoring of blood glucose.
    • Need to be consistent with reporting ranges, either 29.9 – 91.7% or 26.0 to 97.0%.
    • The upper limit of ranges reported in the results suggest some persons had high rates of adherence. The conclusion needs revision to reflect this data.
    Introduction
    • Comma needed on line 7 after ‘diabetes’.
    • Line 26 – space needed after full stop.
    • Line 29 – one set of brackets only needed for references.
    • Line 45 – should be ‘regularly’.
    Background
    • Page 3, line 5 - remove space after brackets.
    • Page 3, line 15 – spell out SSA at first use.
    Search methods and strategy
    • Page 4 line 24 – fix brackets.
    • Page 5 lines 11-12 – fix brackets.

    Results
    • Page 7 line 19 – report number, percentage not appropriate to report due to small number.
    • Page 7 line 24 – should be remainder, not reminder.
    • Page 7 line 29 – add IQR before numbers in brackets.
    • Page 10 line 17 – missing full stop and space needed prior to brackets.
    Discussion
    • Where possible, report median adherence rates for each behaviour from the included studies.

    Reviewer: 2

    Comments to the Author
    The paper mostly relies on descriptive summaries. Yet I have a few comments that need to be addressed to improve the statistical presentation, as indicated below:

    • Page 1, “Aim” section: Please double-check the use of ()-brackets and make sure to properly close brackets: “…self-monitoring of blood glucose (SMBG and foot care)…”

    • Page 4, “Search methods and search strategy” section: Please double-check the use of ()-brackets and make sure to properly close brackets: “The British Nursing Index (listed in our published protocol (Mogre, Johnson, et al., 2017)…

    • Pages 20-31, Tables 1-5: Where the mean adherence or mean measure is stated in these tables, the standard deviation or another measure for the spread or variation in the data distribution should be provided. In addition, the sample size used in each study should be listed together with the means reported.

    Reviewer: 3

    Comments to the Author
    This review has sort to approach the important question of adherence in respect of diabetes self-management behaviours, focussing on LMIC. The review sort to present evidence on adherence to a range of self-management behaviours including lifestyle, medicines and foot care. However, I am afraid that the review contains studies with a high level of heterogeneity in terms of definitions of adherence and quality. More fundamentally, I am struggling to understand what the review can tell us in respect of adherence. In the discussion the authors rightly highlight the fact that self-management behaviours will be regulated by external factors such as a economics and health care provision. So to make a point about adherence to blood glucose testing when in many low income countries test strips are not always available is misleading. This is the dilemma with this review they have no data on explanatory factors and cannot consider whether adherence deficits are individual or structural. If they could address either of these then arguments could be made either for more educational intervention or targeted resources to support diabetes care in these countries. Unfortunately, the review cannot do this. Furthermore, the divergent adherence metrics used across studies limits any comparison so to say that adherence ranges from X to Y using different metrics, in non-comparable samples is misleading. Some of the adherence parameters were incredibly ill defined such as practical foot care. What does practical foot-care include and the validity of interpreting this in a self-report based on a one week window is likely to be unreliable. I also wondered whether authors might have considered a sensitivity analysis comparing findings from low and middle income countries. Throughout the paper the authors risk over stating or interpreting their data; and in the limitations they consider that previous reviews may have been too stringent on regulating the inclusion of studies with their study providing a complete picture as platform for future studies. If that was the intention, I would suggest the authors consider reworking their review as a critical analysis of previous studies, particularly in relation to standards for adherence and how these might be measured at both the individual and structural levels; such that there is a clearer picture for future studies which may want to address this question.

    To revise your manuscript, log on to ScholarOne Manuscripts: http://mc.manuscriptcentral.com/jan

    Please use red font to indicate the revised portions of your manuscript (no tracked changes or strike-through please).

    Please ensure that you detail the changes you have made in the 'comments to decision letter' section of the submission process. I would be grateful if you could also upload your response as a separate, anonymous file (in the 'upload files' stage of the submission process) when you submit your revised paper.

    GENERAL POINTS TO REMEMBER:

    • It is essential that you format your manuscript using the author guidelines for the type of paper you submitted: https://onlinelibrary.wiley.com/page/journal/13652648/homepage/forauthors.html

    • Use APA style for citations and references – please see the author guidelines: https://www.apastyle.org/learn/faqs/index.

    • Your revised word count must not exceed 5000 words for the text, exclusive of the abstract, references, tables and figures.

    • Format the headings like this: main headings upper case, major sub-headings lower case, subsidiary sub-headings italics.

    • The international relevance of the topic should be indicated in the Introduction section of the paper.

    • The Conclusion section should not be a summary or repetition of previous content. This section should provide a discussion of the implications for practice or policy and recommendations for further work.

    • For Review and Discussion papers, provide the inclusive years of literature searched in both the abstract and the text (not the year(s) when the literature was searched).

    • The abstract should not include abbreviations or references.

    • Please include up to 10 key words, including nurse or nursing, which should follow the abstract. Please note these do not have to match the keywords selected in ScholarOne, which are to assist with assigning reviewers.

    SEARCH ENGINE OPTIMISATION:

    Tips for making sure articles can be easily found online are available in the attached PDF.

    Please ensure that your keywords accurately reflect the content of your manuscript.

    I look forward to receiving your revised paper. Please do not hesitate to contact me at jan@wiley.com if there is anything in this letter that needs more explanation.

    Thank you choosing JAN for your paper.

    Yours sincerely,

    Professor Robyn Gallagher
    Editor
    Journal of Advanced Nursing

    Decision letter by
    Cite this decision letter
    Reviewer report
    2019/03/13

    This review has sort to approach the important question of adherence in respect of diabetes self-management behaviours, focussing on LMIC. The review sort to present evidence on adherence to a range of self-management behaviours including lifestyle, medicines and foot care. However, I am afraid that the review contains studies with a high level of heterogeneity in terms of definitions of adherence and quality. More fundamentally, I am struggling to understand what the review can tell us in respect of adherence. In the discussion the authors rightly highlight the fact that self-management behaviours will be regulated by external factors such as a economics and health care provision. So to make a point about adherence to blood glucose testing when in many low income countries test strips are not always available is misleading. This is the dilemma with this review they have no data on explanatory factors and cannot consider whether adherence deficits are individual or structural. If they could address either of these then arguments could be made either for more educational intervention or targeted resources to support diabetes care in these countries. Unfortunately, the review cannot do this. Furthermore, the divergent adherence metrics used across studies limits any comparison so to say that adherence ranges from X to Y using different metrics, in non-comparable samples is misleading. Some of the adherence parameters were incredibly ill defined such as practical foot care. What does practical foot-care include and the validity of interpreting this in a self-report based on a one week window is likely to be unreliable. I also wondered whether authors might have considered a sensitivity analysis comparing findings from low and middle income countries. Throughout the paper the authors risk over stating or interpreting their data; and in the limitations they consider that previous reviews may have been too stringent on regulating the inclusion of studies with their study providing a complete picture as platform for future studies. If that was the intention, I would suggest the authors consider reworking their review as a critical analysis of previous studies, particularly in relation to standards for adherence and how these might be measured at both the individual and structural levels; such that there is a clearer picture for future studies which may want to address this question.

    Reviewed by
    Cite this review
    Reviewer report
    2019/03/02

    The paper mostly relies on descriptive summaries. Yet I have a few comments that need to be addressed to improve the statistical presentation, as indicated below:

    • Page 1, “Aim” section: Please double-check the use of ()-brackets and make sure to properly close brackets: “…self-monitoring of blood glucose (SMBG and foot care)…”

    • Page 4, “Search methods and search strategy” section: Please double-check the use of ()-brackets and make sure to properly close brackets: “The British Nursing Index (listed in our published protocol (Mogre, Johnson, et al., 2017)…

    • Pages 20-31, Tables 1-5: Where the mean adherence or mean measure is stated in these tables, the standard deviation or another measure for the spread or variation in the data distribution should be provided. In addition, the sample size used in each study should be listed together with the means reported.

    Reviewed by
    Cite this review
    Reviewer report
    2019/03/01

    • This is a robust systematic review and well written paper. The appropriate systematic review reporting guidelines (PRISMA) and quality assessment tool (NHLBI Quality assessment tool) have been used. The systematic review was also registered with PROSPERO. The methods are applicable and the reporting of results is clear and concise.
    • My main concerns with the paper are the lack of information about the reasons for excluding the 4008 articles excluded based on titles and abstracts. The authors need to provide summary information and some examples to describe the decision-making process.
    • The paper also requires the number of papers identified in each separate database (either in the results text or Figure 1 and the number of papers excluded from each database after scanning the titles and abstracts.
    • To assist the reader to form an overview of the evidence, where possible and appropriate, report median adherence rates for each behaviour from the included studies. E.g. dietary adherence rates ranged from 29.9% to 91.7%. What was the median dietary adherence found through synthesising the evidence? It may also help to report a mean or median (where appropriate) across the relevant studies for mean number of days participants adhered to diet.
    • The authors should not report percentages for small numbers (e.g. as reported in paper - 59%, n=16). Report either n=16 or 16 out of 27.
    Abstract
    • Foot care is included erroneously in the brackets after self-monitoring of blood glucose.
    • Need to be consistent with reporting ranges, either 29.9 – 91.7% or 26.0 to 97.0%.
    • The upper limit of ranges reported in the results suggest some persons had high rates of adherence. The conclusion needs revision to reflect this data.
    Introduction
    • Comma needed on line 7 after ‘diabetes’.
    • Line 26 – space needed after full stop.
    • Line 29 – one set of brackets only needed for references.
    • Line 45 – should be ‘regularly’.
    Background
    • Page 3, line 5 - remove space after brackets.
    • Page 3, line 15 – spell out SSA at first use.
    Search methods and strategy
    • Page 4 line 24 – fix brackets.
    • Page 5 lines 11-12 – fix brackets.

    Results
    • Page 7 line 19 – report number, percentage not appropriate to report due to small number.
    • Page 7 line 24 – should be remainder, not reminder.
    • Page 7 line 29 – add IQR before numbers in brackets.
    • Page 10 line 17 – missing full stop and space needed prior to brackets.
    Discussion
    • Where possible, report median adherence rates for each behaviour from the included studies.

    Reviewed by
    Cite this review
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