Approximately 4.5 million South Africans have type 2 diabetes – a condition characterized by high blood sugar levels. It can be treated with medication and managed through healthy eating and exercise. But if not managed well, it can be life-threatening. Diabetes is one of the leading causes of death in South Africa.
Blood sugar levels rise to dangerous levels when the pancreas does not produce enough insulin, a hormone that regulates the movement of sugar in the body.
As diabetes progresses, insulin injections become the only treatment option. But the transition from oral medication to injectable insulin is often bumpy. Managing a patient with insulin requires that patients inject at least once a day and measure their blood sugar levels at least twice a day. In addition, health care workers must have the knowledge, skills, and time to monitor patients and adjust the insulin dose when necessary.
To address this problem, we developed an intervention called the Tshwane Insulin Project. Our intervention combines different elements. One is a digital tool, the Vula app, that health professionals can use to communicate with each other.
Another aspect of the intervention involves community health workers in the care of people with diabetes. We also train healthcare professionals at primary care level to manage people living with diabetes, including those who need insulin.
Our intervention is a more efficient way to manage people with diabetes because healthcare providers share the tasks of patient education, insulin initiation and follow-up. The intervention also reduces the number of referrals from clinics to hospitals due to lack of doctors or lack of skills to manage patients with insulin.
When a person’s blood sugar is not controlled with two medications, they get the correct information about insulin and why it is needed. If the patient agrees to take insulin, the doctor prescribes it and the primary care nurse informs the patient.
The mobile app is very useful in primary healthcare settings because the doctor can send a prescription remotely using the app. Patients should not wait for doctors to visit the facility. The nurse can check if the patient meets the criteria for insulin therapy and the doctor can confirm this, remotely, based on the information provided by the nurse.
After the patient starts taking insulin, the nurse contacts the team of community health workers assigned to the clinic to inform them about the new patient.
Community health care workers are a very important part of this intervention.
Before the intervention, patients were sent home with a large amount of information to digest on their own. They must remember how, where and when to inject their insulin; how to take the right dose; how to measure their sugar levels; how to identify when their sugar levels are low (hypoglycaemia); and what to do at that moment.
Research shows that this can be overwhelming for patients. Some are illiterate, with limited medical knowledge. With the involvement of community health workers in the intervention, patients are no longer alone. Patients are visited at home weekly. Community health workers remind patients of key education messages, injection sites and techniques.
Community health workers are also important in adjusting insulin doses. Before the intervention, most patients would adjust their insulin doses during clinic visits – which happened once a month at best – because they could not do it themselves. Insulin is always started at a low dose for safety reasons and to help the patient adjust. Then the dose is increased progressively until the optimal dose is reached. This optimal dose varies from patient to patient. When the dose is adjusted only once a month, it takes a long time to reach the final dose. Many patients never reach that dose and remain with high glucose levels despite the injection.
With our intervention, during the weekly home visit, community health workers communicate the blood sugar level to the doctor through the mobile application. The doctor evaluates the sugar levels and indicates whether the dose of insulin should be increased, decreased or maintained. With weekly dose adjustments, the patient reaches the optimal insulin dose faster and the condition is controlled more quickly. The ability to adjust a patient’s insulin dose as often as weekly thanks to the team making a home visit is a game changer.
The insulin project intervention was tested with a limited number of patients in ten clinics in the Tshwane district of South Africa. The results of this test are promising. There were no reports of low blood sugar, which meant the intervention was safe. Patients who completed the 14-week follow-up with home and clinic visits recorded a 2.2% reduction in their glycated hemoglobin, or HbA1c, meaning their blood sugar was better controlled after the intervention.
We are currently conducting a large-scale evaluation of the intervention.
The remaining obstacles
There is a lot of misinformation about insulin. As a result, some people with type 2 diabetes perceive progression from oral medication to insulin as a sign of failure. Even worse, some believe that insulin means death is near.
We also found high rates of insulin refusal by patients – up to 50% in some areas. Many patients are not meeting their treatment goals. They remain on oral therapy with high blood sugar levels, which leaves them exposed to serious complications.
In addition, many health care professionals, especially those working in primary care clinics, are not equipped to manage patients who need insulin. Their lack of skills and knowledge can contribute to patients’ fears. And community health workers are in short supply. The number of community health workers is estimated at 55,000 for the whole country, which is not enough considering the needs of the population. The Medical Research Council estimated that South Africa needs 41,000 more to bring the total to 96,000.
Despite all these challenges, we are confident that interventions like ours can improve the management of people living with diabetes. The support of health authorities and healthcare workers is essential for successful implementation.