Diabetes knowledge of nurses in sub-Saharan Africa: a scoping review

Abstract

Objective

Nurses are expected to effectively manage and educate the growing number of patients with diabetes in sub-Saharan Africa. This review aimed to map and describe literature relating to the nurses’ diabetes knowledge and the factors promoting and hindering the acquisition of their knowledge.

Setting

Sub-Saharan Africa.

Design

Scoping review.

Methods

A systematic literature search was conducted in electronic databases, such as CINAHL, PubMed, Scopus, African Journals Online and Web of Science and grey literature. Authors and experts in diabetes care and scoping reviews were also contacted. Included studies were assessed using the inclusion criteria developed in advance. Searches were conducted between March and June 2020 and updated in November 2024. Results were presented descriptively.

Results

A total of 2974 records were retrieved through systematic database and hand searches, resulting in 1900 records when duplicates were removed. Of these, 250 potentially relevant studies were identified for thorough assessment for eligibility. The process yielded 20 studies that focused on diabetes knowledge among nurses in sub-Saharan Africa. Most studies reported gaps in diabetes knowledge among nurses including pathology, laboratory investigations, insulin therapy, type two diabetes treatment, exercise, diet and complications. Barriers to diabetes knowledge acquisition included lack of hospital guidelines, staff, training and inadequate salary. Facilitators included experience in managing or counselling patients with diabetes and refresher nutrition courses.

Conclusion

Nurses in sub-Saharan Africa have gaps in diabetes knowledge. Further research is required on tailor-made strategies for enhancing the nurses’ diabetes knowledge and implementation of the same to prepare nurses and other clinical team members to effectively care for, support and teach patients with diabetes.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This review followed a rigorous approach and systematic literature searches in multiple databases and grey literature.

• Explicit eligibility or inclusion criteria for selecting studies were applied.

• The review included studies conducted in multiple healthcare settings which might have also led to heterogeneity.

• There might be other unpublished studies in sub-Saharan Africa which were not detected by our search.

• Critical appraisal of individual sources of evidence was not formally done, although a brief summary is provided.

Background

Diabetes mellitus (herein referred to as diabetes) is a chronic metabolic disorder characterised by increased levels of blood glucose (BG) (hyperglycaemia), resulting in gradual and severe complications on the heart, blood vessels, eyes, kidneys and nerves.¹ It has been referred to as the global health emergency of the 21st century with a prevalence of 537 million and a projected prevalence of 783 million by 2045 if no prompt action is taken.² Diabetes was also listed among the top 10 causes of death globally.³ Unfortunately, the highest number of people living with diabetes and the vast majority of years lived with disability and deaths attributable to diabetes and other non-communicable diseases (NCDs) are in low- and middle-income countries (LMICs).⁴

Sub-Saharan Africa (SSA), a region comprising LMICs, is experiencing a surge in the diabetes prevalence leading to an enormous health and economic burden.⁵ The region is expected to have about 40 million people with diabetes by 2035.⁶ Despite being home to 11.4% of people with diabetes globally, the region has the lowest investment in diabetes care, with only 10 billion US$ spent on diabetes, representing a mere 1% of the total spent worldwide.⁷ As such, it is not surprising that resources for diabetes care are scarce⁴ and the quality of diabetes care is poor in SSA.⁸ As the number of hospital admissions associated with diabetes and its complications is increasing steadily in the region,^{9 10} frontline health workers, such as nurses, are striving to cope with the complex care demands of diabetes in low-resource settings.¹¹

Diabetes is a complex and challenging NCD which requires healthcare workers to have the capacity to provide optimal levels of care for the patients.12,14 However, appropriate care and management interventions have proven to halt diabetes progression and minimise complications.¹⁵ Evidence also demonstrates that nurses have an important role to play in diabetes care and have a major effect when supporting patients with self-management of their condition, particularly using the proactive care management model and decision-making support approaches.16,22 Similarly, a scoping review demonstrated that nurse-led diabetes self-management education programmes tailored to patients’ culture, context and language lead to improvements in clinical, psychological and behavioural outcomes among patients with diabetes in SSA.²³ Therefore, nurses are at the heart of diabetes care²⁴ and their knowledge and expertise in diabetes care are considered to be crucial for the survival and well-being of the patients with diabetes.²⁵

The initial search in CINAHL and EMBASE using the terms “nurses,” “knowledge,” “diabetes,” and “care” revealed several studies which indicated low knowledge of diabetes and its care among nurses and other healthcare professionals, which often results in poor care, errors and unfavourable patient as well as clinical outcomes.1226,38 A scoping review also found nurses to be actively involved in NCD management in Africa, although they had varying levels of knowledge hindered by nurse shortages, inadequate training and facilitated by comprehensive training, supervision and mentorship among other factors.³⁹ However, it was unclear what kind of information was available in literature about what nurses in LMICs, particularly in SSA, knew specifically about diabetes care and the factors associated with the acquisition of their diabetes knowledge. For these reasons, a scoping review was conducted in order to systematically map research done in this area and identify any existing gaps in knowledge.

Objectives and questions

This scoping review was conducted to map and describe literature relating to diabetes care provision in SSA. The following questions were formulated for this scoping review:

• What is known about nurses’ knowledge about diabetes in hospital settings in SSA?

• What is known about the nurses’ knowledge for managing adults with diabetes in SSA?

• What is known about the factors hindering and promoting nurses’ acquisition of diabetes knowledge in hospital settings in SSA?

Methods

This review was underpinned by a scoping methodological framework to map and describe literature relating to the nurses’ knowledge of care of adults with diabetes in hospital settings in SSA. The methodological framework for conducting scoping reviews, proposed by Arksey and O’Malley 39, included the following steps: identifying the research question; searching for relevant studies; selecting studies; charting data; and collating, summarising and reporting the results. The objectives, inclusion criteria and review methods were developed in advance. However, the protocol for this review was not pre-registered. Furthermore, scoping reviews do not appraise the quality of included studies in any formal way.^{40 41} Therefore, studies included in this review were not formally assessed for quality, although a brief summary is provided. The review was reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines.⁴²

Inclusion criteria

Population

This scoping review considered all studies that focused on nurses who are involved in provision of care for adults with diabetes in hospital settings. The hospital setting was considered because evidence shows a surge in the number of patients reporting to health facilities with diabetes and its complications in SSA.⁹ Consideration was also made for studies focusing on healthcare professionals which nurses were part of.

Concept

The scoping review considered all studies that addressed the following: nurses’ knowledge of diabetes in hospital settings in SSA; nurses’ knowledge of care provided to adults with diabetes in hospital settings in SSA; and factors associated with the acquisition of knowledge for managing adults with diabetes in hospital settings.

Context

The review considered all studies which explored the care provision for adults with diabetes in hospital settings in SSA encompassing the following regions: Central Africa; East Africa; West Africa; and Southern Africa. This was because SSA is reported to be the last region to enter the epidemiological transition where NCDs are imposing both public health and socioeconomic burdens on individuals, communities and societies.⁶ The new World Bank’s country classifications were used to determine a country’s income level where necessary.⁴³

Types of studies

Both observational and experimental study designs published in English were considered for inclusion in this scoping review. No limits were put on the source of evidence, as this approach yields greater sensitivity in the search, a practice preferred for scoping reviews.⁴⁴

The review considered both quantitative and qualitative studies, including mixed methods studies. Quantitative designs included randomised controlled trials, non-randomised controlled trials, quasi-experimental studies, pre- and post-intervention studies, case-control studies, prospective and retrospective cohort studies and descriptive and analytical cross-sectional studies. Qualitative approaches included ethnography, grounded theory, phenomenology, action research and descriptive-exploratory. However, opinion papers and letters were excluded.

Outcomes

The scoping review sought to map literature and present the range of outcomes within the topic. Therefore, the scoping review considered the following primary outcomes for nurses: knowledge of diabetes types, pathophysiology, clinical manifestations and complications; knowledge of diagnostic tests, BG monitoring, normal values (cut-off points) and commonly used medications; and knowledge about management of diabetes and complications: both medical and nursing management. The following was the secondary outcome for nurses: barriers and facilitators in both diabetes care and knowledge acquisition: personal (physical, psychological), organisational and support systems.

Exclusion criteria

Studies were excluded if they addressed the following areas: diabetes care involving student nurses; care in the community or homes; care of children with diabetes; care of pregnant women with diabetes; and care in higher-income countries or outside SSA.

Search strategy

The search strategy aimed to retrieve both published and unpublished studies written in English from 2000 to 2024. The year 2000 was chosen as the start date because it was at the start of the third millennium when NCDs were identified as increasing in prevalence in LMICs, such as SSA.⁴⁵ A stepwise approach to the search strategy was used in this review. An initial was conducted using keywords from the topic. Second, a comprehensive search of all keywords and all relevant index terms was conducted (between 1 March and 30 June 2020, last updated on 9 December 2024) in the following electronic databases: CINAHL, PubMed, Scopus, African Journals Online and Web of Science. The search terms included Medical Subject Headings (MeSH) and “free text” words in combination. Keywords and indexing terms and their synonyms were combined using the Boolean operators AND for concepts and OR for synonyms. Search terms were adapted according to the particular database. A copy of the PubMed search is provided in table 1 below, and the search strategy for all the databases is in the online supplemental file 1.

Table 1. Search terms used in PubMed.

Search	Query
#5	Search ((#5) AND #4) AND #3 AND #2 AND #1
#4	Search “Africa”(MeSH] OR “Africa South of the Sahara”(MeSH] OR “Congo”(MeSH)OR “Tanzania”(MeSH] OR “Guinea-Bissau”(MeSH] OR “Eritrea”(MeSH] OR “Libya”(MeSH] OR “Comoros”(MeSH] OR “Equatorial Guinea”(MeSH] OR “Zimbabwe”(MeSH] OR “Zambia”(MeSH] OR “Uganda”(MeSH] OR “Togo”(MeSH] OR “Swaziland”(MeSH] OR “Sudan”(MeSH] OR “South Africa”(MeSH] OR “Somalia”(MeSH] OR “Sierra Leone”(MeSH] OR “Senegal”(MeSH] OR “Rwanda”(MeSH] OR “Mozambique”(MeSH] OR “Mauritania”(MeSH] OR “Mali”(MeSH] OR “Malawi”(MeSH] OR “Madagascar”(MeSH] OR “Liberia”(MeSH] OR “Lesotho”(MeSH] OR “Kenya”(MeSH] OR “Cote d’Ivoire”(MeSH] OR “Ghana”(MeSH] OR “Nigeria” [MeSH] OR “Gambia”(MeSH] OR “Gabon”(MeSH] OR “Ethiopia”(Mesh] OR “Chad”(Mesh] OR “Central African Republic”(MeSH] OR “Cameroon”(MeSH] OR “Burundi”(MeSH] OR “Burkina Faso”(MeSH] OR “Botswana”(MeSH] OR “Benin”(MeSH] OR “Angola”(MeSH] OR “Sao Tome and Principe”(MeSH] OR “Democratic Republic of Congo”(MeSH)
#3	“Nurses”(Mesh] OR “Carers” [MeSH] OR “Healthcare Providers”(MeSH] OR “Health Workers”(MeSH)
#2	“Knowledge”(MeSH] OR “Awareness”(MeSH] OR “Comprehension”(MeSH] OR “Competency”(MeSH] OR “Health Knowledge”(MeSH)
#1	“Diabetes Mellitus” [MeSH] OR “Hyperglycemia”(MeSH] OR “Obesity”(MeSH] OR “Weight Gain”(MeSH] OR “Overweight” OR “Metabolic Disease” [MeSH)

Lastly, references from retrieved articles were searched for additional studies that may not have been captured by the comprehensive search. A search in Open Grey yielded no results. Google Scholar search was not included in this review due to its limitations in search control, replicability and precision. Authors (Christine Atsalos) and experts (Judith Carrier, Elizabeth Gillen) were contacted to seek more published, unpublished, ongoing studies and guidance on evidence synthesis in low-resource settings. All the citations retrieved were exported into and managed by a reference software (Zotero) and all unnecessary duplications were removed. Screening for relevant studies, including title and abstract and full-text screening, was conducted by two reviewers independently. Reasons for exclusion were documented accordingly and are presented in the flow chart (figure 1). Literature was screened using Covidence (www.covidence.org). All articles that met the inclusion criteria had their full texts retrieved.

Figure 1. A flow chart showing details of the citations. SSA, sub-Saharan Africa.

Data extraction

Results for the scoping review were extracted based on the review aims and literature. The data extracted included study characteristics such as authorship, year of publication, geographical location; study design such as study type, aim(s), population, sample size, patient care setting, methods used; and main outcomes, such as diabetes knowledge assessed and barriers and facilitators reported. Data were extracted by the first author (MN) and checked by the second author (BG). Authors met regularly to discuss and resolve disagreements between reviewers. One primary study author was contacted for additional information.

Data synthesis

Results were discussed in narrative form. Descriptive studies were synthesised and presented in a table. Descriptive statistics, such as percentages and frequencies, were used to provide a narrative summary of the characteristics of the studies where appropriate. Literature was tabulated based on the headings relating to study characteristics, such as authorship, year of publication, geographical location, study design such as study type, aims, population, sample size, care setting, methods and outcomes. Where a systematic review was identified, the number of studies included in the systematic review that potentially met our inclusion criteria was noted, and those missed by our search were included in the results.

Results

The electronic database and hand searches retrieved a total of 2974 citations. These resulted in 1900 citations after removal of duplicates. The titles and abstracts of these citations were screened and 250 citations were considered for further thorough assessment of the full article for eligibility. This process yielded a total of 20 citations for inclusion in this review, 4 of which were retrieved through hand searching. Figure 1 below is a flowchart showing details of citations at each step.

Characteristics of the included studies

Country and year of publication

Included studies were published between 2005 and 2024. There were more studies published in 2014 (n 3, 15%)46,48 and 2015 (n 3, 15%)^{33 49 50} than the other years. These studies were conducted in Ethiopia (n 1, 5%),⁵¹ Nigeria (n 4, 20%),4752,54 Malawi (n 2, 10%),^{46 55} Rwanda (n 1, 5%),⁵⁶ Ghana (n 2, 10%),^{49 50} Libya (n 1, 5%),⁵⁷ Mauritius (n 1, 5%),⁵⁸ Uganda (n 1, 5%),³³ South Africa (n 4, 20%),59,62 Tanzania (n 1, 5%),⁴⁸ Kenya (n 1, 5%)⁶³ and South Sudan (n 1, 5%).⁶⁴ Online supplemental table 2 summarises the included studies and their results.

Aim of the study

The included studies assessed various areas of diabetes care among nurses and other health workers. Whereas seven studies (35%) specifically assessed diabetes/diabetes care knowledge among nurses,4749 53 56,58 64 one examined diabetes knowledge in conjunction with attitudes⁶² and others (10%) included attitudes and practices towards diabetes/diabetes care and foot care respectively.^{59 61} One study evaluated the nurses’ self-efficacy and performance of self-management support (SMS) on top of assessing their knowledge.⁶⁰ Two studies (10%) focused on diabetic foot ulcers (DFUs): one set out to assess the nurses’ knowledge and attitude towards DFU⁵¹; and the other one examined the nurses’ knowledge, attitudes and practices regarding diabetic foot care.⁶¹ Another study measured the nurses’ knowledge and associated factors in the nutritional management of diabetes.⁵⁰ While the above studies focused on diabetes or some aspects of diabetes care, three studies (15%) focused on NCDs, particularly the health workers’ knowledge of selected NCDs, such as hypertension, diabetes and chronic respiratory disease⁵² and the burden of chronic diseases and service readiness for diabetes and cardiovascular disease (CVD).^{33 55} One study set out to assess the quality of care provided to patients with diabetes in which nurses’ and clinicians’ knowledge was explored.⁴⁶

Research design

The majority of the included studies (n 18, 90%) were cross-sectional studies.3346,57 59 While some studies included the type of the cross-sectional study, for example descriptive (n 5, 25%),^{46 49 59 61 64} others indicated exploratory (n 1, 5%),⁵⁵ simple correlational (n 1, 5%)⁶⁰ and others just indicated survey (n 3, 15%).^{47 57 62} Two studies (n 2, 10%) used qualitative designs: descriptive, exploratory⁶³ and phenomenology.⁵⁸ Quantitative studies included in this review utilised different knowledge measurement tools as follows: the Diabetes Basic Knowledge Test (n 2, 10%); University of Michigan Diabetes Research and Training Centre Knowledge Questionnaire (n 2, 10%); O’Brien’s Diabetes knowledge questionnaire (n 2, 10%); knowledge test based on American Diabetes Association and WHO guidelines (n 1, 5%); case-scenario based questionnaire (n 2, 10%); and researcher-designed questionnaires (n 9, 45%). The included qualitative studies used semi-structured interview guides designed by the researchers (n 2, 10%).

Sample and sampling

The samples varied widely in the included studies. The majority of the included studies (n 13, 65%) recruited nurses only,4749,51 53 54 56 58 whereas the rest (n 7, 35%) included other health workers in addition to nursing staff.^{33 48 52 55 61 62 65} Similarly, the size of the sample varied massively from 2 to 401. Only one study did not specify the number of nurses included, despite indicating the total number of the participating health workers.⁵⁵

The included studies utilised both single and combined sampling strategies. The majority of studies (n 11, 55%) used single sampling strategies, such as random,^{47 51 64} convenience,^{59 60 63} total population,^{56 61} consecutive,⁴⁶ stratified³³ and purposive.⁵⁸ Other studies (n 3, 15%) used combined sampling strategies, such as consecutive and convenience,⁵⁴ stratified and systematic⁵² and convenience and purposive sampling.⁵⁵ The rest of the included studies (n 6, 30%) did not clearly indicate the sampling strategies.4648,50 53 57

Patient care settings

Patient care settings varied across the included studies from dispensaries or clinics to referral hospitals. While some studies (n 5, 25%) were conducted in primary healthcare (PHC) facilities,5258,61 others (n 2, 10%) focused on district or secondary hospitals.^{46 62} Some studies (n 4, 20%) were conducted at referral and teaching hospitals.^{54 57 63 64} Some studies were conducted in more than one care setting, such as referral and district hospitals (n 3, 15%),^{49 51 56} university teaching, central and private hospitals (n 1, 5%),⁵³ regional and district hospitals and health centres (n 2, 10%)^{33 48} and public, private and faith-based health facilities (n 1, 5%).⁵⁵ Two studies (10%) only indicated hospitals⁵⁰ and government hospitals⁴⁷ without any specification of the level of the facility.

Outcomes of the review

The primary outcomes of this review were two-fold: the nurses’ knowledge of diabetes; and their knowledge regarding the management or care of patients with diabetes. The secondary outcome related to factors associated with the nurses’ diabetes knowledge. This section presents the findings regarding these outcomes

Nurses’ knowledge of diabetes

Three papers included in this review specifically assessed the nurses’ knowledge of diabetes.^{49 53 57} One of these studies evaluated the level of professional nurses’ knowledge in type 2 diabetes. Only 32.4% had good knowledge in type 2 diabetes and the majority (68.4%) had poor knowledge of diabetes complications.⁴⁹ These nurses were drawn from a university teaching hospital and two training centres for health professionals in Ghana. Two studies assessed diabetes knowledge of nurses and identified knowledge gaps: one found unsatisfactory knowledge levels among nurses alongside knowledge deficits in acute complications of diabetes⁵³; another one found knowledge gaps, particularly in DKA, and identified basic knowledge of diabetes, pathology, laboratory investigation, type 2 diabetes treatment, insulin therapy, exercise, diet and complications as areas for educational programme.⁵⁷

Four studies assessed the knowledge of health workers, including nurses, in diabetes alongside other NCDs or chronic diseases.^{33 48 52 55} One comparative, cross-sectional study found that the majority of nurses (69.6%) in rural local government areas (LGAs) were knowledgeable about hypertension, diabetes and chronic respiratory disease as compared with those in urban LGAs (54.8%) in Nigeria.⁵² Another cross-sectional study that assessed the burden of chronic diseases and service readiness found that 60% of the urban, peri-urban and rural nurses had fair knowledge of diabetes, but only 5% were comfortable to manage a patient with diabetes in Uganda.³³ Similarly, a cross-sectional study in Tanzania found that 49% of the nurses had fair knowledge of diabetes but only 4% were comfortable to manage patients with diabetes.⁴⁸

Nurses’ knowledge of diabetes management or care

Nine studies included in this review assessed knowledge of nurses regarding diabetes care.4756 58,60 62 Of these, three (15%) studies found that the majority of the nurses had adequate knowledge of diabetes care.^{60 63 64} For instance, a descriptive, cross-sectional study in South Sudan found that 57% of the nurses correctly answered questions on diabetes care.⁶⁴ Similarly, a South African cross-sectional study found that all the participating nurses had a score of ≥50% in diabetes SMS, with 75% having a score of ≥75% and 64% having a score of ≥80%.⁶⁰ Also, a study in Kenya found that most nurses (73.3%) had adequate knowledge in the management of patients with diabetes.⁶³ However, the other studies (n 5, 25%) found that few nurses demonstrated low or inadequate knowledge of diabetes management as compared with those that had adequate knowledge.^{47 56 58 59 62} Two of these studies (10%) indicated that few nurses demonstrated the accuracy of knowledge regarding various aspects of diabetes care, such as BG monitoring, diet, exercise, stress management, treatment, complications and symptom management.^{56 59} The other studies indicated that the majority of nurses had inadequate knowledge of various aspects of diabetes care, such as holistic diabetes care,⁵⁸ diabetes diets, exercises, BG monitoring and foot/skin care⁴⁷ and general management of diabetes including best site for insulin injection and symptoms of hypoglycaemia.⁶² One exploratory facility-based survey that assessed the readiness of health facilities to provide diabetes and CVD care found that nurses and other health workers lacked knowledge in diabetes and CVD care.⁵⁵

Three of the included studies assessed the nurses’ knowledge, attitudes and practices relating to specific aspects of diabetes care, such as nutritional management and foot care.^{50 51 61} Two of these studies focused on foot care and found that the majority of the participating nurses were knowledgeable about prevention, risk and management of DFU including the diabetic foot guideline.^{51 61} Although almost all participants in one study demonstrated a positive attitude towards foot care,⁶¹ only 43.3% had a favourable attitude towards diabetic foot care in the other study.⁵¹

Factors associated with the nurses’ diabetes knowledge

A wide range of factors were associated with the nurses’ diabetes knowledge as clearly demonstrated by four (20%) of the included studies. Facilitating factors were location, years of experience, NCD and nutrition training attendance and experience in managing patients with diabetes in Nigeria.⁵² In Ghana, the nurses’ knowledge of nutritional management of diabetes was associated with those who had a refresher course in nutrition, counselled a diabetic patient and took 2–3 nutrition courses in school.⁵⁰ Interestingly, another study in Nigeria found that nurses with 1–5 years of experience had higher scores than those with more years of experience.⁴⁷ Barriers included lack of hospital guidelines, inadequate nurse-patient ratio, insufficient salary to motivate staff and lack of resources for training in South Sudan.⁶⁴ These are summarised in box 1.

Box 1. Factors associated with the nurses’ diabetes knowledge.

Facilitating factors

• Refresher course in nutrition, involvement in diabetic patient counselling and taking 2–3 nutrition courses in school in Ghana.⁵⁰

• Years of experience (1–5 years) in Nigeria.^{47 52}

• Location (rural) in Nigeria.⁵²

• Direct involvement in the provision of diabetes care in Nigeria.⁵²

Barriers

• “How can I improve without acquiring new knowledge?” in Kenya.⁵⁸

• Inadequate NCD training in Nigeria.⁵²

• Poor availability of guidelines in Nigeria⁵² and South Sudan.⁶⁴

• Inadequate nurse-patient ratio, insufficient salary to motivate staff and lack of resources for training in South Sudan.⁶⁴

The other studies identified challenges in diabetes care in addition to health workers’ knowledge gaps, such as shortage of medicines, lack of time, shortage of human and material resources, lack of diagnostic equipment, weak training and reporting systems, lack of clear policies and community engagement, low job morale and patients’ illiteracy, poverty and denial of their chronic condition.^{33 46 55 58 63}

Discussion

This scoping review mapped and described literature relating to diabetes knowledge and factors promoting and hindering the acquisition of diabetes knowledge among nurses in hospital settings in SSA. Twenty studies were reviewed across different countries and healthcare settings, thereby enabling the establishment of nurses’ knowledge of different aspects of diabetes care. The review focused on studies conducted within a 24-year period to enable the observation of changes in research approaches, quality and diabetes knowledge gaps. For instance, studies conducted between 2005 and 2008 employed qualitative research approaches because it was observed that there was little nursing research on diabetes knowledge.⁶³ Subsequently, studies started focused on objective assessment of diabetes knowledge utilising validated and standardised knowledge tools, such as the O’Brien diabetes knowledge questionnaire and the University of Michigan Diabetes Research and Training Centre knowledge test, to ensure a comprehensive assessment of the nurses’ knowledge of various aspects of diabetes and care. This approach enabled the identification of specific knowledge gaps relating to diabetes and care among nurses. Furthermore, this transition signalled evolution in the measurement of diabetes knowledge among nurses in SSA.

The findings showed deficiencies in the nurse’s knowledge of different aspects of diabetes and its care, such as diabetes pathology, complications, BG monitoring, type 2 diabetes treatment, insulin therapy, treatment complications, diet, exercise, stress management, symptom management, foot/skin care and areas for education. The factors that promoted the nurses’ acquisition of diabetes knowledge included location, experience in managing and counselling patients with diabetes, additional nutrition courses and in-service (NCD) training. Interestingly, one study found that nurses with 1–5 years of experience had higher scores than those with more years of experience. However, lack of hospital guidelines, inadequate nurse-patient ratio, insufficient salary to motivate staff and lack of resources for training were associated with inadequate diabetes knowledge among the nurses. In addition, this review identified challenges in diabetes care which encompassed a lack of human and material resources.

The findings of this review are not entirely new. Although the review only focused on the 24 years after the booming of NCDs in SSA, the findings from earlier studies are consistent with the findings of this review. For instance, a US study in 1989 reported that nurses could not give correct answers to questions on BG monitoring and insulin storage and handling.⁶⁶ Similarly, a study of diabetes knowledge among nurses in long-term care facilities reported that a significant proportion of nurses answered incorrectly questions on diabetes diet (53%) and diabetes care and management (61%).⁶⁷ Low diabetes knowledge levels were also shown in a UK study, whereby 40% of the mental health nurses had fair knowledge of diabetes, with only 24% and 15% demonstrating good and very good knowledge about diabetes respectively.⁶⁸ The study also identified the following diabetes care areas in which nurses required training: foot care (19%), dietary advice (63%), and monitoring glucose intake (22%) and BG monitor (68%). Consistent with these findings, a UK study found that almost half of the registered nurses from a teaching hospital had knowledge gaps in BG monitoring.²⁹ Diabetes knowledge deficits among nurses and other healthcare professionals were also reported in developing countries such as Jordan,⁶⁹ Pakistan,⁷⁰ Uganda³⁶ and Cameroon.³¹ Various factors promoting and hindering the nurses’ acquisition of diabetes knowledge have been identified elsewhere. For instance, a study in Saudi Arabia identified individual-level factors, such as lack of interest to acquire new knowledge and limited time, and organisational factors, such as work overload, limited access to training and guidelines as threats to the acquisition of diabetes knowledge among nurses.⁷¹ Various studies have also identified various factors promoting the acquisition of diabetes knowledge by nurses, such as exposure to patients with diabetes,⁷² in-service training and educational programmes.⁷¹

This study has important recommendations for policy and practice. First, we strengthen the call for diabetes training or educational opportunities for nurses and other frontline healthcare workers to ensure that they perform their roles effectively.^{47 63 68} Second, we suggest the inclusion of core diabetes competencies in nursing curricula across SSA. These include diabetes pathophysiology and epidemiology, clinical skills, such as BG monitoring, medical and complication management and culturally appropriate education on diet and self-management.⁷³ Third, health facilities should harness existing cost-effective educational programmes, such as continuing professional development (CPD) as a strategy for enhancing diabetes knowledge among nurses. Evidence shows that CPD has the capacity to enable nurses to maintain their professional competence and increase their self-esteem,⁷⁴ thereby positively influencing the nurse’s clinical practice and management of patients with diabetes.¹⁵ However, further research should focus on identifying tailor-made strategies for adapting such educational interventions to local contexts, particularly where resources are constrained. Furthermore, technology offers prospects for improved capacity for healthcare providers in diabetes care. For instance, artificial intelligence (AI) has demonstrated potential for simplifying diabetes management among healthcare providers through clinical decision support, such as detection and monitoring of diabetes and its comorbidities.⁷⁵

This review has some strengths. To our knowledge, this is a comprehensive scoping review that mapped and described the diabetes knowledge of nurses in SSA, a region characterised by paucity of literature relating to diabetes and other NCDs. The scoping review also utilised a methodological framework by Arksey and O'Malley 39, a rigorous approach that has not been extensively used in SSA. Moreover, this review was conducted through systematic literature search in various databases and grey literature. Lastly, local and international experts in scoping reviews and diabetes care were contacted for guidance.

The review was not without limitations. First, the results of our review must be interpreted with caution, given the heterogeneity of the diabetes knowledge measurement tools and the data collected. However, we decided to include all the identified studies in the analysis because we were able to draw the findings relating to the nurses’ diabetes knowledge levels from these studies. The decision was also underpinned by the nature of scoping reviews as a form of evidence synthesis that systematically identifies and maps the breadth of available literature on a specific topic. Second, the review was limited to LMICs, particularly SSA, to yield contextualised findings in order to lay the foundation for future studies towards the enhancement of diabetes care in the region. Third, the review considered studies published in English due to resource constraints and, therefore, those from Francophone Africa may have been missed, thereby limiting the generalisability of the results. It is also important to note that the protocol for this review was not pre-registered. Lastly, the review included studies conducted in multiple healthcare settings which might have also led to heterogeneity. However, the ability to draw consistent outcomes from different healthcare settings added credit to the review.

Conclusion

This study has mapped and described literature relating to the knowledge of diabetes and its care among nurses in SSA. Generally, the findings show various knowledge gaps in various aspects of diabetes and its care, such as pathology, complications, BG monitoring, pharmacological and non-pharmacological management, treatment complications and areas for education. Factors promoting diabetes knowledge acquisition included location, experience in managing and counselling patients with diabetes and training and refresher courses in diabetes. Barriers to diabetes knowledge acquisition included lack of interest to acquire new knowledge, lack of guidelines, inadequate nurse-patient ratio, insufficient salary to motivate staff and lack of resources for training. This review recommends further research on tailor-made educational strategies for enhancing the nurses’ and other healthcare providers’ diabetes knowledge and inclusion of core diabetes competencies in the nursing curricula across SSA to prepare nurses to effectively care for, support and teach patients with diabetes.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.