Diabetes is a growing epidemic and is the second biggest cause of death in South Africa, behind tuberculosis (TB). In Africa, it is responsible for more deaths than malaria, HIV and TB combined. With an increasing number of people with type 2 diabetes in need of insulin treatment, researchers at the University of Pretoria (UP) are making use of a digital insulin management approach to treat under-resourced patients in their homes and local clinics. In the process, they are transforming diabetes care.

One of South Africa’s greatest challenges in controlling the diabetes epidemic is the initiation of insulin and adjusting the doses of insulin (known as titration) to achieve glycaemic control at primary care level. Individuals with type 2 diabetes are often referred to a higher level of care to start insulin treatment due to inadequate support systems in primary care. They are also unable to access blood glucose monitors and test strips to monitor their own blood glucose levels.

In South Africa, diabetes management guidelines recommend that insulin be initiated by a doctor. However, in primary care settings, doctors are not always available to prescribe insulin due to a shortage of healthcare workers. For many South Africans with diabetes, accessing quality care close to home is a huge challenge.

Eli Lilly scientist at work_Photo courtesy of Eli Lilly

Cognisant of these limitations, and the need to address this national challenge, the Department of Internal Medicine in the University of Pretoria’s Faculty of Health Sciences established a collaborative project among several departments at the University in 2018. Known as the Tshwane Insulin Project (TIP), collaborators included UP’s departments of Internal Medicine, Family Medicine, Nursing Science, Exercise Science, and Human Nutrition, and the School of Health Systems and Public Health, as well as national and local health authorities.

The primary objective of the project is to optimise the control of blood glucose, blood pressure and lipids in people with diabetes, with a focus on initiation and titration of insulin by primary care nurses and physicians. Fundamentally, treatment has to be more accessible, especially in vulnerable communities, which is why the project had to find innovative ways to enable primary care nurses and physicians to treat patients.

The project is supported by a five-year funding grant from Eli-Lilly (through the Lilly Global Health Partnership). It entails research into the viability of using telehealth to help primary care physicians and nurses to better serve the needs of people living with diabetes in under-resourced areas. Telehealth has not been widely used in South Africa to manage insulin therapy in primary care settings.

Following extensive research and evaluation of various options that could assist nurses and primary care physicians in outlying areas in the absence of a prescribing doctor, the TIP decided to make use of a readily available option in the form of the Vula mobile application (app). This app, with its secure medical chat and referral function, enables nurses to reach out to a doctor when a patient needs to be put on insulin. The advantage of this intervention is that it involves the doctor remotely, both in terms of prescribing and adjusting the insulin dose.

According to Dr Patrick Ngassa Piotie, Project Manager of the TIP, an existing mobile app was chosen due to the fact that it had been developed locally, was available to healthcare providers free of charge and had been endorsed by the National Department of Health.

This intervention was designed to fit into South Africa’s Integrated Chronic Disease Management (ICDM) model, which aims to reduce healthcare utilisation and promote self-management among patients with chronic conditions. Dr Ngassa Piotie wants to see this project making a difference in communities. “In this way, we will have succeeded in translating scientific knowledge into practical solutions that impact on people’s lives.”

The project’s first activity was the appointment of full-time fieldworkers who could go into the communities and visit patients in their homes, and who could visit primary care clinics. Starting in January 2019, the development of the intervention proceeded according to several sequential phases, culminating in the development of an intervention called the TIP intervention, which would support people with type 2 diabetes as they transition from oral drugs to insulin.

The initial planning phase of the intervention involved conducting interviews with doctors, nurses and patients, and reviewing files to identify any gaps in diabetes care. This was followed by a pilot study in mid-2019 to assess the feasibility of the intervention in facilitating the initiation and adjustment of insulin.

The intervention was piloted at 10 clinics, where 23 patients were put on insulin safely. Following the successful implementation of the pilot, the project was ready to be rolled out in various regions in Tshwane from February 2020. Despite the impact of the COVID-19 pandemic, the project team is making progress towards reaching their target of 60 clinics in the Tshwane area.

Follow-up with patients who have been involved in the TIP digital intervention has shown that the intervention works. More than 80 patients with type 2 diabetes who had previously been poorly controlled have now been safely and successfully initiated on insulin, and their control has improved.

Among the key components of the TIP intervention is the involvement of community health workers in diabetes care. The project’s fieldworkers are training community health workers about basic diabetes care and how to conduct home visits to check that patients who have been initiated on insulin are doing well. During the home visits, community health workers are making sure that patients know how to test their blood sugar and inject insulin correctly. The community health workers are also equipped with diabetes education material, which enables them to discuss topics like a healthy diet and exercise with the patient in order to educate them about their condition. In this way, they empower patients and their families to take part in their care, and to help motivate the patient to make better choices.

Several important achievements can already be reported, the most significant of which is the fact that, due to the advocacy efforts of the TIP, people with diabetes who are on insulin treatment can now obtain glucose meters and test strips from their local clinics. Furthermore, over 700 healthcare professionals have been trained in the integrated management of diabetes and hypertension in primary care settings through workshops organised by the TIP and the Tshwane district.

While the project has managed to address several challenges in diabetes management, some challenges remain, including the resistance of healthcare providers to initiate patients on insulin, as well as patients who are afraid of taking insulin. “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,” said Dr Ngassa Piotie.

Dr Ngassa Piotie and Prof Rheeder are adamant that diabetes should achieve the same recognition as other chronic diseases, such as HIV and TB, where the care and management of the disease has been brought closer to the communities. This is essential if the quality of diabetes treatment and care at primary level is to improve.

Following the success achieved with the project to date, and the national importance of research focusing on diabetes in resource-constrained settings, the University of Pretoria approved the establishment of the University of Pretoria Diabetes Research Centre in November 2020. This institutional endorsement can only benefit the national effort to promote better care for South Africans living with diabetes.