Approximately 4.5 million South Africans have type 2 diabetes, a condition characterized by high blood sugar levels. It can be treated with drugs and controlled through healthy eating and exercise. But if not managed properly, 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 complicated. Managing a patient with insulin requires that patients be injected 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 their insulin dose when necessary.
To solve this problem, we developed an intervention called the Tshwane Insulin Project. Our intervention combines several elements. One is a digital tool, the Vula app, that healthcare professionals can use to communicate with each other.
Another aspect of the intervention involves community health workers in caring for people with diabetes. We also train health professionals at the 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 health care professionals share the tasks of patient education, initiation, and insulin monitoring. The intervention also reduces the number of referrals from clinics to hospitals due to the unavailability of physicians or lack of skills to manage insulin patients.
The intervention
When a person’s blood sugar is not controlled with two drugs, he gets the right 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 care settings because the doctor can send a prescription remotely through 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, remotely, based on the information provided by the nurse.
Once the patient is started with insulin, the nurse contacts the team of community health workers assigned to the clinic to inform them of the new patient.
Community health workers are a very important part of this intervention.
Prior to the intervention, patients were sent home with a wealth of information to digest on their own. They should remember how, where and when to inject their insulin; how to get the right dose; how to measure your sugar levels; how to identify when your sugar levels are low (hypoglycemia); and what to do at that time.
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 every week. Community health workers remind patients of key educational messages, injection sites, and techniques.
Community health workers are also important in adjusting insulin doses. Prior to the intervention, most patients had their insulin doses adjusted during clinic visits, which were done once a month at best, because they could not do it themselves. Insulin is always started at low doses for safety reasons and to help the patient adapt. The dose is then gradually increased until the optimum dose is reached. This optimal dose varies from patient to patient. When the dose is adjusted only once a month, it takes too long to reach the final dose. Many patients never reach this dose and are maintained with high glucose levels despite being injected.
With our intervention, during the weekly home visit, community health workers communicate blood sugar levels to the doctor through the mobile app. Your doctor will assess your sugar levels and indicate whether you should increase, decrease, or maintain your insulin dose. With weekly dose adjustments, the patient achieves the optimal dose of insulin more quickly 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 intervention of the insulin project was tested with a limited number of patients at ten clinics in the Tshwane district in South Africa. The results of this trial 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 reported 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.
Remaining obstacles
There is a lot of misinformation about insulin. As a result, some people with type 2 diabetes perceive the progression of oral medication to insulin as a sign of failure. Even worse, some believe that insulin means death is near.
We have also found high rates of insulin rejection by patients, up to 50% in some areas. Many patients do not meet their treatment goals. They remain in oral therapy with high blood sugar levels leaving them exposed to serious complications.
In addition, many health 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 scarce. The number of community health workers is estimated at 55,000 for the entire country, which is not enough given 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 health workers is crucial for successful implementation.