Technology and home visits could help South Africans with diabetes manage insulin

About 4.5 million South Africans have type 2 diabetes – a condition characterized by high blood sugar levels. It can be treated with medications and managed with healthy eating and exercise. But if not properly managed, it can be life-threatening. Diabetes is one of the leading causes of death in South Africa.

Blood sugar rises to dangerous levels when the pancreas doesn’t make enough insulin, a hormone that controls the movement of sugar in the body.

As diabetes progresses, insulin injections become the only treatment option. But the transition from oral medications to injectable insulin is often a bumpy one. To treat a patient taking insulin, patients should inject at least once a day and measure their blood sugar at least twice a day. In addition, healthcare workers must have the knowledge, skills and time to monitor patients and adjust the insulin dose if necessary.

To address this problem, we have developed an intervention, the Tshwane Insulin Project. Our intervention combines several elements. One of these is a digital tool, the Vula app, that allows healthcare professionals to communicate with each other.

Another aspect of the intervention is that community health professionals are involved in the care of people with diabetes. We also train healthcare professionals at the primary care level to guide people with diabetes, including those who need insulin.

Our intervention is a more efficient way to treat people with diabetes because healthcare providers share the tasks of patient education, insulin initiation and follow-up. The intervention also reduces referrals from clinics to hospitals due to unavailability of physicians or lack of skills to treat patients taking insulin.

The intervention

When a person’s blood sugar isn’t controlled with two drugs, they get the right information about insulin and why it’s needed. If the patient agrees to start taking insulin, the doctor prescribes it and the primary care nurse informs the patient.

The mobile app is very useful in primary care as the doctor can send a prescription remotely via the app. Patients do not have to wait for doctors to visit the facility. The nurse can verify that the patient meets the criteria for insulin therapy and the doctor can confirm this remotely based on the information provided by the nurse.

Once the patient starts taking insulin, the nurse contacts the health care team assigned to the clinic to inform them about the new patient.

Social care providers are a very important part of this intervention.

Before the intervention, patients were sent home with a huge amount of information that they had to process themselves. They should remember how, where and when to inject their insulin; how to draw the correct dose; how to measure their sugar levels; how to identify when their 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 professionals in the intervention, patients are no longer alone. Patients are visited at home every week. Community health professionals remind patients of important educational messages, injection sites and techniques.

The community health workers are also important in adjusting the insulin dosage. Before the intervention, most patients had their insulin dosage adjusted during clinic visits—which happened once a month at most—because they couldn’t do it themselves. For safety reasons and to help the patient adapt, insulin is always started at a low dose. Thereafter, the dose is gradually increased until the optimal dose is reached. The optimal dose differs 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 that dose and continue to have high glucose levels despite injecting.

With our intervention, during the weekly home visit, the community health workers communicate the blood sugar levels to the doctor via the mobile app. The doctor assesses the sugar levels and indicates whether the insulin dose should be increased, decreased or maintained. With weekly dose adjustments, the patient reaches the optimal insulin dose more quickly and the condition is controlled earlier. 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 has been tested on a limited number of patients at ten clinics in South Africa’s Tshwane district. The results of this trial are promising. There was no report of low blood sugar, making the procedure safe. Patients who completed the 14-week follow-up with home and clinic visits registered a 2.2% reduction in their glycated hemoglobin or HbA1c, meaning their blood sugar levels were better controlled after the intervention.

We are currently conducting a large-scale evaluation of the intervention.

Remaining hurdles

There is a lot of misinformation about insulin. As a result, some people with type 2 diabetes see the switch from oral medications to insulin as a sign of failure. Worse, some believe that insulin means death is near.

We also found high rates of insulin refusal by patients – as much as 50% in some areas. Many patients fail to meet their treatment goals. They remain on oral therapy with high blood sugar levels exposing them to serious complications.

In addition, many health care professionals, especially those who work in primary care clinics, are not equipped to treat patients who need insulin. Their lack of skills and knowledge can contribute to patients’ fears. And there is a shortage of health workers in the community. The number of health workers in the community 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 will need 41,000 more to bring the total to 96,000.

Despite all these challenges, we are convinced that interventions like ours can improve the treatment of people with diabetes. The support of health authorities and health professionals is crucial for a successful implementation.

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