Feasibility of Managing Diabetes Patients Identified Through Community Screening in Rural Ethiopia

Abstract

ABSTRACT Objective To assess the feasibility of diagnosing, enrolling, and managing adults with type 2 diabetes at the primary healthcare level using the WHO Package of Essential Non-communicable Disease Interventions (WHO-PEN) approach, following identification through community – based screening in rural Ethiopia. Design Single-arm, pre-post clinical feasibility study. Setting Primary healthcare facility in Shebedino district, Sidama National Regional State, rural Ethiopia, between September 2024 and February 2025. Participants 35 adults with newly diagnosed type 2 diabetes, identified through community-based screening and diagnosed according to the WHO and American Diabetes Association criteria. Interventions A six-month WHO-PEN based intervention comprising metformin based pharmacologic treatment, lifestyle counselling, and health system strengthening. Outcome measures Feasibility across four domains (acceptability, implementation fidelity, practicality, and preliminary clinical signal); HbA1c change from baseline to six months, analysed using the Wilcoxon signed-rank test and McNemar’s test. Results All 35 patients completed the six-month follow-up. At baseline, 6(17 %) had comorbid hypertension, 5 (14%) had elevated total cholesterol, 14 (40%) had low HDL cholesterol, 24 (69%) were underweight. Median HbA1c decreased from 52.0 mmol/mol (IQR: 50-56.0) at baseline to 43.0 mmol/mol (IQR: 42.0-46.0) at six months (reduction of 9.0 mmol/mol; p <0.001). By six months, 30 of 35 (85.7%) had HbA1c below the control threshold, versus 20 (57%) at baseline (p=0.002). Conclusion Community-identified adults with type 2 diabetes could be successfully diagnosed, linked to care, and retained using the WHO-PEN approach at a rural primary healthcare facility, with substantial improvement in glycaemic control. The absence of a control group precludes causal attribution. Medication was not adjusted for patients with persistent hyperglycaemia despite scheduled reviews, indicating a priority need to strengthen implementation of established practices rather than studying further efficacy. STRENGTHS AND LIMITATIONS ❖ This is the first clinical feasibility study to evaluate implementation of the WHO-PEN approach for diabetes management at the primary healthcare level in rural Ethiopia, assessed using a structured, multi-domain feasibility framework. ❖ Patients were identified and linked to care through a pre-established community-based screening rather than passive health facility attendance, reducing selection bias and enabling assessment among newly diagnosed adults within the community. ❖ This is among the first studies to report diabetes management outcomes in a population with a prevalence of underweight (69%), contributing evidence on diabetes care among undernourished populations in Ethiopia. ❖ The single-arm, pre-post design, conducted at a single sit without a concurrent comparison group, limits the ability to attribute ❖ The study identified implementation gaps, including the absence of medication dose adjustment for patients above the HbA1c target during follow-up, despite scheduled review visits at three and six months.