The practice of using glucometers for self-monitoring of blood glucose (SMBG) is an essential component for care and management of diabetes,^1,2 which is supported by educational and clinical guidelines.^3,4 Information generated from SMBG is shared with healthcare teams for modification of multiple self-care behaviours and simplifying problem-solving discussions.^5,6 Numerous sources of error have been reported to affect blood glucose testing using glucometers, including clinical, operators, reagent, environmental, software, and hardware.⁷ Despite the myriad of challenges, glucometers have undergone evident technological and methodological improvements in recent times.⁸ Although conflicting reports exist pertaining to the accuracy and reproducibility of glucometers, evaluation have showed decreased reliability and non-compliance with some international standards of certain brands,^8,9 while increased sensitivity and specificity have been reported for other brands.^10,11 Compared with central laboratory testing for blood glucose using auto-analysers, enhanced performance has been observed for most glucometers, despite quality control concerns.^9,12,13

Outpatient glucometers differ from those found in hospital settings, resulting in heterogeneity of operators and multi-directional studies. Because of the diversity of glucometer operators, some studies^{14,15,16,17,18,19} have assessed the knowledge, attitude and practice of individuals living with diabetes type 1 and 2 using glucometers for routine SMBG, while other studies^{20,21,22,23,24,25} evaluated knowledge, competency and experience of healthcare practitioners (HCPs) operating glucometers.

Researchers’ efforts to develop an operator’s assessment checklist²⁶ and a self-management model²⁷ for HCPs and patients are yet to be fully recognised and accepted by international regulatory organisations. Ensuring patient safety and reducing medical errors are key components of global best practices.²⁸ Integrating point-of-care tests (POCTs) into laboratory management information systems is necessary in order to allow bidirectional information exchange and traceability.²⁹ The lack of or inadequate HCP formal training, as well as the absence of or inadequate quality control materials and practices, have been reported as major concerns for using glucometers for blood glucose monitoring and patient care.^30,31,32,33

Studies conducted in Northern Nigeria have shown poor quality control practices for glucometers, and inadequate or lack of training for HCPs, to be major challenges facing the use of glucometers as a point-of-care device in the region. Although studies have accessed either knowledge, competence or experience among HCPs, limited studies have investigated the trio in Jigawa and Kogi States of Nigeria, where the study was conducted. The objectives of the study were to assess knowledge, estimate competence and measure experience of HCPs using glucometers for patient care in two states of Northern Nigeria.

Our study found a paucity of theory and skills for glucometer calibrators and calibration in about half of the participants, which in turn impacts the frequency of calibration of the device by HCPs, reliability and reproducibility of test results obtained, and the quality of life of the patients. Unavailability of SOPs for blood glucose testing using glucometers was reported by many respondents, despite the accessibility of training in some healthcare facilities.

About two-thirds of participants knew glucometers existed as a point-of-care device utilised for patient care. This is because over the years, glucometers have gained wide acceptability as an SMBG tool and point-of-care device. A study²³ at Tygerberg Hospital located in the northern suburbs of Cape Town, Western Cape, South Africa, in 2016, which assessed knowledge and awareness of POCTs, reported that 97% of participants had performed blood glucose testing using glucometers. However, by restricting participation to only doctors and nurses, the study excluded other HCPs who were likely to operate the device. Another study²² in Nigeria, at the University of Benin Teaching Hospital and Central Hospital, Edo State, Southern Nigeria, in 2015, reported good knowledge of POCT (50.6%) among doctors, but the finding is not comparable to our study because of non-specification of POCT devices and restricted enrolment of study participants to only doctors.

We observed that work experience, or years of service, for most respondents ranged between 1 and 10 years (41.2%) and 11 and 20 years (38.4%), showing that years of HCPs’ service or work experience in patient care was not directly linked with knowledge about existence of the device and its use. This implies that HCPs may not have to practise for many years before becoming acquainted with glucometers. Similarly, an assessment of nurses’ competencies in diabetes care,²⁰ in Anambra State, Southeast Nigeria, in 2023, showed a positive association between duration of work experience and skills. However, the skills were diverse and not limited to blood glucose testing using glucometers. As a result, deductions from the study aren’t comparable to our study.

Nearly half of the respondents (49.2%) reported not securing formal training or certification prior to first use of glucometers in patient care. This is because most health facilities in the private or public sector in Nigeria rely solely on device manual inserts provided by manufacturers to guide HCPs as a substitute for formal training or certification. Similarly, a multi-centre study by Nnakenyi et al.,³⁰ conducted in Enugu Southeast Nigeria in 2017 across five health facilities, found documentation for personnel training in only 26% of POCT sites, for which glucometers accounted for about 65% of the point-of-care devices in use. Inadequate formal training^22,23 for HCPs remains a major setback for achieving accuracy and reliability in blood glucose testing using glucometers. Lack of or inadequate training translates to limited theoretical knowledge²⁰ and skills that may negatively impact quality assurance, quality control, and quality management systems, as a whole. Limited knowledge of operators, particularly HCPs, can lead to misdiagnosis, inaccurate test results, flawed research reports and wrong therapeutic interventions. When knowledge is poor, practice is hampered, hence the need to educate HCPs on the importance of seeking knowledge and skills required for operating point-of-care devices such as glucometers.

Some studies have suggested in-service training on POCTs for doctors, nurses and midwives^20,21,22,23 in Nigeria and South Africa. The need to train other cadres of HCPs is less advocated in studies, despite the presence of such professionals in a standard POCT organogram as stipulated in international guidelines. Three-quarters of participants (75.1%) reported in the affirmative regarding availability of a training forum for HCPs on glucometers in their health facilities. Despite the availability of the training forums, HCPs do not deem it necessary to secure formal training or certification preceding first use in patient care. Hospital in-service training provides an avenue for HCP continuous professional education and development. Other sources, such as conferences, journal articles, and pharmaceutical companies, have also served as sources of information for HCPs on POCT.³¹

Although more than half of respondents (66.5%) were aware of the existence of glucometer calibrators, many (41.2%) didn’t know what purpose calibrators specifically served in SMBG. This may be attributed to the fact that most new glucometers do not come with calibrators in their packs, and those with calibrators lacked an operation manual.¹³ Thus, the necessity to harmonise theorical knowledge and skills for most HCPs. More than half of respondents (58.2%) did not possess theoretical knowledge about glucometer calibration, and a similar number of respondents (64.6%) had no practical experience of glucometer calibration, which is supported by reports of some studies^11,23 conducted in South Africa, 2020, and Australia, 2025. Theoretical knowledge is crucial for operators of glucometers in order to identify factors which may either affect the testing device or strips, leading to underestimation or overestimation of blood glucose when using the device.

The essence of calibration is for early detection of device non-conformances and ensuring results obtained are accurate and reproducible. Studies in Douala, Southwest Cameroon,⁸ in 2014–2015 and Calabar, Southsouth Nigeria,^9,13 in 2021, have evaluated the functional capacity of glucometers using calibrators provided by some brands. The frequency of glucometer calibration varied among respondents and about half (48.2%) reported to have never calibrated a glucometer, despite years of service in patient care. Responses showed that the ideal way of calibrating glucometers which is before first use, weekly, and after purchasing a new vial of test strips is not practised by most HCPs in Nigeria. Likewise, Inaku et al.,³² in a survey of POCT use among doctors and nurses in Calabar, Southsouth Nigeria, 2019, reported that 24.3% of participants performed quality control practices on POCTs in use of which glucometers accounted for 91.4% of the POCTs. The study reported poor quality control among doctors and nurses operating the devices. Regulation of POCT use was also suggested by the majority of respondents in the study. Limited knowledge of glucometer calibration among HCPs,⁹ as reported in a study in Calabar, Southsouth Nigeria, 2019, translates to erroneous results and unsatisfactory patient outcomes,¹³ as supported by a study in Enugu Southeast Nigeria, 2022. Periodic calibration of glucometers is recommended in order to prevent misdiagnosis, improve test result quality, minimise mismanagement of patients and achieve beneficial outcomes that will impact quality of life of end-users.

Certain brands of glucometers have exhibited superiority in terms of precision and accuracy, even without necessarily meeting certain international standards for POCTs.^8,10,11 This has led to product bias among HCPs and patients, with increased competition for manufacturing companies. Healthcare practitioners are expected to know when results tend towards incorrectness, especially when managing high-risk patients such as those on admission in intensive care units, to prevent misdiagnosis.²³ Half of the participants (50.0%) reported observing inconsistency of test results obtained from the same glucometer operated at different times. The finding may be attributable to the myriad of technical challenges and sources of errors associated with blood glucose testing using glucometers.

About half of respondents (43.6%) rated the accuracy of glucometers as 51.0% to 99.0%, and 17.6% reported its accuracy as 100.0% when compared to central laboratory testing for blood glucose. In recent times, increased accuracy and precision for some glucometers have been reported,^2,10 although there are contrary findings.^8,9 The comparison of our finding with other reports may not be accurate because of differences in study designs: descriptive cross-sectional versus comparative analytical prospective. Glucometer operators should be knowledgeable about operational limitations of certain brands of the device used for blood glucose testing. Suggestions to keep point-of-care devices, such as glucometers, under the laboratory department has been faced with a lot of opposition, because such devices are dedicated for near patient testing. Healthcare practitioners should be equipped with knowledge of limitations of the device and when to refer testing for critical patients to the central laboratory.

Standard operating procedures are sets of step-wise instructions containing elements of quality assurance and quality control which conform with regulatory guidelines for end users. Robust training, supervision and intensive quality assurance mechanisms are necessary to optimise blood glucose testing using glucometers.³⁴ Unavailability of SOPs for glucometers in most health facilities accounted for 56.5% of responses. Provision of teaching aids and SOPs in the form of flow charts or simple checklists for glucometers is essential in achieving quality blood glucose testing. Absence of SOPs for blood glucose testing using glucometers in health facilities may impact negatively on operators’ proficiency and quality of results generated using the device.²³

Most studies in sub-Saharan Africa^22,23,30 have broadly assessed POCTs as an entity and considered glucometers only as a subset of POCT, with study participation limited to specific healthcare cadres: doctors, nurses, midwives, or laboratory professionals. For instance, an multi-centre study³⁰ in Enugu Southeast Nigeria, 2017, glucometers accounted for 65% of the POCTs, and participation was restricted to doctors, nurses, and laboratory personnel. The notable findings were lack of traceable patient test records, troubleshooting faulty devices by non-laboratorians, and poor method validation observed at the study sites. Absence of a POCT committee in all study hospitals was observed in all study sites. Another study²² in Edo State, Southern Nigeria, in 2015, conducted at two tertiary health facilities assessed knowledge and utilisation of POCT among doctors. The study did not specify the types of POCTs assessed, what was assessed, the reason for the assessment, and participation was restricted to only doctors. A hospital audit²³ at Cape Town, Western Cape, South Africa, in 2016, which evaluated the knowledge of POCT best practices among clinical staff, precisely doctors and nurses, suggested the need for formal training and competency assessment for operators. The reasons for limiting participation to doctors and nurses only was not clearly defined. A survey of POCT devices among doctors and nurses³² at Calabar, Southsouth Nigeria, in 2019, also showed that most operators used POCT devices for disease monitoring. The POCTs evaluated were glucometers, urine testing strips, haemoglobin meters, bilirubin meters, and cholesterol meters. The non-restriction of the POCTs to glucometers, differences in study designs, and limitation of participation to specific cadres of HCPs in other studies, may not allow for appropriate comparison with the present study.

In Nigeria, operating glucometers in hospital settings is not restricted to a specific cadre of HCPs.²² All HCPs involved in patient care, irrespective of training, years of experience and skills, automatically become operators of the device³² because of the lack of organograms for POCTs in Nigerian hospitals. The unavailability of hospital-based POCT committees may also be responsible for some irregularities observed in some health institutions. Our study was carefully designed to identify gaps and proffer solutions to the spate of blood glucose testing using glucometers in Nigeria.

Currently, there is no regulatory agency or national guideline in Nigeria dedicated to POCTs or glucometers, and there are no POCT committees in hospitals. Organising centralised local, state or national POCT training or certification in Nigeria may encourage stakeholders in government, health, science, and technology, as well as the private sector, towards engagement of HCPs in developing policies, creating hospital committees on POCTs, and implementation of policies at the grassroots.