Diabetes is a killer in South Africa. It is the second highest natural cause of death in the country, after tuberculosis, and the main cause of death among women.
Across the country, the management of the estimated 4.6 million people with diabetes, mostly type 2 – that is, caused by lifestyle rather than genetics – is below par, which is why a University of Pretoria (UP) research project is breaking new ground by striking at the heart of the problem.
Funded by the Lilly Global Health Partnership, the Tshwane Insulin Project (TIP) is a methodical hands-on approach that targets people living with type 2 diabetes where they are first encountered – in the primary health care system.
The aim of the project is not about creating highfalutin theory but about helping patients. TIP’s Project Manager, Dr Patrick Ngassa Piotie, said: “The research is described as from ‘bench to the patient’s bedside’. The goal is not to produce a research report. We want to see our research making a difference in the communities and the patients benefiting. That’s why we call it translational research, where we translate scientific knowledge into practical solutions that impact the way people are doing things.”
Sister Sophie Phiri hands a patient the Tshwane Insulin Project pack, which includes a glucose metre, test strips and a diabetes education booklet.
Medical doctor Ngassa Piotie is more than just TIP’s Project Manager. Together with Prof Paul Rheeder of UP’s Department of Internal Medicine, he put together the five-phase proposal. The project started in 2019 and the first three phases formed the backbone of Dr Ngassa Piotie’s pending PhD in Public Health. The objective of the project is to support people with type 2 diabetes as they transition from oral drugs to insulin because of the natural progression of their condition.
Although putting patients onto insulin is the not the first step of managing type 2 diabetes, it can be an integral part of it.
The project started with identifying the barriers and opportunities for putting patients onto insulin. It also reviewed the legal and policy framework for insulin use in primary care; and then went onto a pilot study to test a new model of care to facilitate the initiation and adjustment of insulin. They piloted the intervention at 10 facilities and put 22 patients on insulin. Now during phase four, the model is being implemented in various regions in the Tshwane area.
Dr Ngassa Piotie emphasised the real-life challenges of the research. “It's not like researchers sitting in a laboratory, doing their thing with a microscope in a controlled environment.
“Here we are basically working with the nurse and the doctor in the facilities. If they're in a bad mood, we are affected. That's the challenge in this programme, but it's also a benefit because the goal is that whatever solution we develop, we have already tested it, and we can say to the Department of Health, if you implement it this way, it works. The nurses might have some challenges, but we overcome them together. The doctor might have some challenges, but we address them.
“This is what we call real-world research, we do it with the health professionals themselves. So we have to ensure their buy-in, we have to be diplomatic so that they can come on board and help us to help them,’’ he said.
Tshwane Insulin Project Field Researcher Charles inserts a sensor on the arm of a person living with diabetes.
One of the weaknesses TIP has already identified is that the guidelines say that insulin must be prescribed by doctors. But most primary health care clinics don’t have doctors working there regularly. This used to be the same problem with HIV and initiating patients on antiretrovirals, until the guidelines were adapted to allow nurses to prescribe antiretrovirals. In the TIP intervention, nurses use an award-winning digital app called Vula to reach out to a doctor when a patient needs to be put on insulin. The doctor is involved in the process remotely, both in terms of prescribing and adjusting the insulin dose.
Another challenge they face is the huge, across-the-board resistance to taking insulin. It doesn’t help that it is free. People living with type 2 diabetes and the public at large should be educated about the benefits of insulin, and the myths around insulin must be challenged.
TIP’s model of care is family-focused, that is, it centres on the patient’s home rather than the clinic. It is this principle that Dr Ngassa Piotie believes perfectly places the project in the community-giving spirit of Mandela Month, where UP joins the rest of the country in celebrating former President Nelson Mandela’s birthday month. Community health workers are trained about basic diabetes care and they do home visits to check that the patients who have been initiated on insulin are doing well.
A patient shows off her sensor for continuous glucose monitoring.
“One of the weaknesses in diabetes management in South Africa is that our patients are not empowered or educated about their condition. With TIP, community health workers equipped with a diabetes education booklet visit patients in their homes where they have discussions about topics like healthy diet or exercising. The community health workers also make sure that patients test their blood sugar and inject insulin correctly. Now the family can be part of the care, and can help motivate the patient in making good decisions. Diabetes is all about making good decisions,” said Dr Ngassa Piotie.
“The beauty of those home visits is that we are raising awareness of diabetes as a condition, and diabetes care, and in this way we are reaching the community, one family at a time.”