In South Africa, initiating and managing insulin in primary care for people living with type 2 diabetes (PLWD) is a major challenge. To address these challenges, a multidisciplinary team from the University of Pretoria (South Africa) developed the Tshwane Insulin project (TIP) intervention.
To determine internal and external factors, either facilitators or barriers, that could influence the implementation of the TIP intervention and propose strategies to ensure sustainability.
Tshwane District, Gauteng province, South Africa.
We used the SWOT framework to qualitatively analyse the strengths, weaknesses, opportunities, and threats influencing the implementation of the TIP intervention. Four field researchers and three managers from the TIP team participated in an online group discussion. We also conducted semi-structured interviews with healthcare providers (HCPs) (seven nurses, five doctors) and patients with type 2 diabetes (
Regardless of the identified weaknesses, the TIP intervention was accepted by PLWD and HCPs. Participants identified strengths including app-enabled insulin initiation and titration, pro-active patient follow-up, patient empowerment and provision of glucose monitoring devices. Participants viewed insulin resistance and the attitudes of HCPs as potential threats. Participants suggested that weaknesses and threats could be mitigated by translating education material into local languages and using the lived experiences of insulin-treated patients to address insulin resistance. The procurement of glucose monitoring devices by national authorities would promote the sustainability of the intervention.
Our findings may help decision-makers and health researchers to improve insulin management for PLWD in resource-constrained settings by using telehealth interventions.
The treatment of type 2 diabetes mellitus (T2DM) has moved from specialist centres to primary care settings.
In South Africa, initiating and managing insulin for people living with diabetes (PLWD), especially type 2, are major challenges considering the limited resources of the healthcare system, especially in primary care. These system challenges are exacerbated by patient beliefs and resistance towards insulin and the attitudes of healthcare providers who prefer to delay insulin therapy in spite of patients not achieving glycaemic goals.
To address these challenges related to insulin management in primary care, a multi-disciplinary team from the University of Pretoria in South Africa developed a nurse-driven and home-based telehealth intervention named the Tshwane Insulin project (TIP).
The TIP intervention was developed in four sequential phases following the guidance of the United Kingdom (UK) Medical Research Council (MRC) for designing and evaluating complex interventions.
Currently, there is limited research on the successful implementation and dissemination of telehealth interventions to address insulin initiation and titration in primary care in resource-constrained settings. Here, we report on the internal and external factors, either facilitators or barriers, identified using a SWOT analysis that could affect the implementation and scale-up of the TIP intervention. Based on participants’ feedback, we propose strategies to facilitate the implementation and dissemination of the intervention and ensure its sustainability.
We conducted a SWOT analysis using a qualitative design. The SWOT methodology is structured and allows for a qualitative descriptive and cross-sectional analysis.
The study was conducted in the Tshwane District, which is situated in the northern part of the Gauteng province in South Africa. The population is urban and consists of mixed socioeconomic groups living in traditional and informal dwellings. People who attend the primary care clinics are often from middle to low socioeconomic groups and cannot afford medical insurance. The primary care clinics where the study took place were selected conveniently during the pilot of the TIP intervention (reported elsewhere).
The prevalence of diabetes mellitus in the Tshwane District is unknown; however, suboptimal control for blood glucose and blood pressure as well as high rates of complications have been reported in people with diabetes living in this district.
For this study, we used criterion sampling as a purposive sampling strategy.
After the pilot of the TIP intervention, participants comprising primary care nurses and doctors who were involved in the pilot study and PLWD who were initiated on insulin during the pilot and completed a 14-week follow-up were invited for semi-structured interviews. In addition to the pilot study participants, members of the TIP team were invited to take part in an online FGD. The TIP members were included in the study because they possessed valuable information that had to be included in the evaluation of the strengths, weaknesses, opportunities and threats of the TIP intervention and the implementation process.
We achieved data saturation (1) by including all available participants, (2) by interviewing participants who had different perspectives and (3) by exploring the insights and experiences of doctors, nurses, patients as well as the TIP staff with the TIP intervention and the implementation process.
Healthcare providers and patients with T2DM who were involved in the TIP intervention pilot were interviewed about the benefits and disadvantages of the intervention. The questionnaire was adapted from tools developed by Weiner et al.
We held an online FGD with members of the TIP team in July 2021. The online FGD was facilitated by CF. All participants provided written informed consent. The FGD took 4 h and followed the SWOT analysis framework of first identifying strengths followed by weaknesses, opportunities and lastly threats. The FGD was done on Microsoft Teams and was recorded.
Data from the FGD and the semi-structured interviews were transcribed verbatim by PNP. Then, PNP and CF individually analysed the data manually using the SWOT framework.
The Research Ethics Committee of the Faculty of Health Sciences of the University of Pretoria (Ethics Reference No.: 156/2019) and the Tshwane Research Council (No.: GP_201810_049) approved the study. The study adhered to the Declaration of Helsinki. Written informed consent was obtained from all participants.
A total of 31 people participated in the study. Twenty-five participants comprising seven primary care nurses and five medical officers who were involved in the pilot, and 13 PLWD accepted the invitation and were interviewed. In addition, six members of the TIP team took part in the FGD: three were part of the management team, whilst the remaining three were field researchers.
The internal aspects (strengths and weaknesses) that characterised the TIP intervention are summarised in
Strengths and weaknesses (internal aspects) of the Tshwane Insulin Project intervention identified by members of the Tshwane Insulin Project team, healthcare providers and patients.
Strengths | Weaknesses |
---|---|
Promote better diabetes care for PLWD, reduce referrals for insulin initiation and improve patient outcomes. | Education materials written in English. |
Pro-active patient follow-up and support. | |
Empowerment and education of PLWD and their families. | |
Provision of monitoring equipment, consumables and education materials. | |
Innovative telehealth intervention embedded in the ICDM framework. | Reliance on smartphones and on the availability of mobile data and network. |
App-enabled initiation and titration of insulin. | |
Involvement of CHWs with home visits. | Perceived increased workload for clinic staff. |
Simplified protocols and processes aligned to NDOH diabetes management guidelines. | |
Empowerment and training of healthcare providers, sharing best practices. | |
Strong engagement with stakeholders and active consultation. | |
Fostering collaboration amongst healthcare providers. | |
Knowledgeable and competent field researchers. |
CHW, community healthcare workers; ICDM, Integrated Chronic Disease Management; PLWD, People living with diabetes; NDOH, National Department of Health.
After initiating insulin, enrolled patients received a pack containing various items including a blood glucose monitor, test strips, lancets for finger pricking, a diabetes education booklet, a diary for self-monitoring of blood glucose and a sharp container for disposing insulin needles and lancets. Outside of the TIP, patients who are initiated on insulin in South African primary care facilities do not receive glucose monitors and strips. A healthcare professional noted:
‘Mostly I like the fact that patients are given strips and meters for monitoring, because the department [
After initiating insulin, patient follow-up was not limited to monthly clinic visits. In the TIP, patients were visited weekly for 14 weeks by CHWs and TIP field researchers. During home visits, CHWs checked on injection sites and injection technique, monitored home glucose measurements, checked on compliance with the clinic visit schedule and checked for hypo and hyperglycaemia. The CHWs delivered individualised patient education based on patient needs using the diabetes education booklet. Enrolled participants appreciated the additional support:
‘I liked the fact that, they were checking me every week. They gave me machine and strips and they also provided voucher for food parcel.’ (Participant 8, PLWD, female)
Patients who participated in the TIP intervention received adequate education before initiating insulin followed by education sessions during home visits. The sessions focused on improving patient knowledge and understanding of insulin therapy and helping patients to adopt self-care behaviours such as healthy eating, being physically active and monitoring blood glucose. Additionally, home visits encouraged family involvement. Family members were more supportive after attending education sessions. A participant commented:
‘TIP helped me. I can now control my glucose levels. Before TIP, I had no information now I can control my diet through the knowledge I gained.’ (Participant 12, PLWD, female)
The TIP enables primary care nurses to use a mobile app called Vula to connect with a doctor to initiate a patient on insulin. In this setting, PLWD often have limited numeracy skills, health literacy and limited understanding of diabetes, which means that self-titration was not a realistic option. Weekly physician-directed titration enabled by telemedicine and assisted by a CHW allowed participants to reach their optimal insulin dose quicker. At each home visit, CHWs used a mobile app to share the home glucose values of the participants with a doctor who indicated via the app whether the current insulin dose should be increased, decreased or remain unchanged. The ability to titrate insulin remotely was a positive experience for the nurses as demonstrated by the following quote:
‘I like the way the patients are followed up at home. And patients [
Healthcare providers received training in integrated diabetes management and care, which was supplemented by on-the-job training and ongoing support by TIP field researchers. Healthcare professionals became confident in their ability to manage PLWD and to initiate insulin therapy. More patients were initiated on insulin at participating clinics, and the management of PLWD improved with better monitoring (more HbA1c tests done) and optimisation of therapy for patients on oral glucose-lowering drugs. A primary care doctor remarked:
‘The programme is beneficial for the overall management of Type 2 Diabetes and not only the initiation of insulin.’ (Participant 1, male, doctor)
TIP field researchers who were qualified healthcare workers were employed full time and received training in diabetes management and care. The field researchers were assigned to primary care clinics to support PLWD. They would often act as diabetes educators, educating patients on diabetes self-management. The field researchers also assisted healthcare providers in identifying qualifying patients and providing pre-initiation counselling. The field researchers developed good interpersonal relationships and rapport with the healthcare workers, which eased the implementation of the intervention.
The TIP intervention was designed to fit into the ICDM model, which facilitated its integration within the primary South African healthcare system. The intervention showed that inter-professional team-based diabetes care was possible with the help of digital tools such as mobile applications.
The diabetes education booklets distributed to healthcare workers and PLWD were written in English. The TIP education materials were developed in English because many local languages are used in communities where the TIP was implemented, and English seemed to be a practical option. Our SWOT analysis revealed that choosing English constituted a language barrier as many participants were not fluent in English as evidenced by the following statement:
‘To have the booklet in multiple languages that can be understood by many people.’ (Participant 6, PLWD, male)
Although health workers received smartphones and mobile data to use the mobile app, access to mobile networks was sometimes a challenge. Unfortunately, some areas had poor network coverage. Poor network coverage resulted in delays and in some instances insulin titration could not be done from the patient’s home. A health professional noted that:
‘It is a great programme but a problem when there is no network coverage for Vula [
The increased workload was identified as a weakness of the TIP as activities were perceived to be time consuming by some primary care nurses, whose main tasks are to identify patients with suboptimal control, refer patients to a doctor for initiation and counsel patients:
‘Time consuming, because I had [
In addition, patients who were employed full time did not benefit from home visits. The field researchers of the TIP attempted telephonic follow-ups with calls or WhatsApp; however, the procedure needs to be formalised and strengthened.
The external factors, including the opportunities and threats as identified during the SWOT analysis, are summarised in
Opportunities and threats (external factors) of the Tshwane Insulin Project intervention identified by members of the Tshwane Insulin Project team, healthcare providers and patients.
Opportunities | Threats |
---|---|
Presence of a large pool of insulin-requiring PLWD at primary care facilities. | Insulin resistance from PLWD and healthcare providers. |
Utilise lived experiences to advocate for insulin therapy amongst PLWD and promote better diabetes care. | Family and community misconceptions and stigmatisation. |
Family on-boarding programme before insulin initiation. | Low patient health literacy. |
Procurement of monitoring equipment and consumables such as glucose meters and test strips for PLWD in primary care. | Attitudes of healthcare providers. |
Strengthen follow-up strategy for employed PLWD. | Poor compliance with diabetes management guidelines. |
Translation of education materials. | Doctors not responding on time via the mobile app. |
Involvement and training of allied healthcare workers. | Incomplete or unreliable patient records (incorrect contact details). |
Involvement of CHWs in diabetes care. | Health workforce challenges: staff rotation or turnover, overworked and overburdened health workforce. |
Larger number of doctors registering on the digital health platform. | Poor filing and data systems at primary care facilities. |
Employment of Diabetes Educator or Dedicated Diabetes Nurses. | Shortages of insulin, monitoring equipment and consumables. |
Data-free mobile app for initiation and titration of insulin. | Competing priorities at the primary care facilities. |
Wi-Fi roll-out at primary care facilities. | Repeat prescriptions with limited monitoring and follow-up. |
Scaling-up, dissemination of the intervention. | Limited capacity and human resources for patient recruitment, counselling and follow-up. |
PLWD, people living with diabetes; CHWs, community health workers.
The various tasks of the TIP intervention can be shared amongst healthcare workers to ease the load on primary care nurses. For example, health promoters could be trained and be responsible for counselling patients who need to be initiated on insulin. A nurse suggested the following:
‘I would suggest that TIP train people like health promoters so that they can do the counselling of diabetes patients.’ (Participant 7, male, nurse)
The TIP intervention is an opportunity to train CHWs to care for PLWD. The CHWs are able to reach out to patients in their homes and deliver basic educational information that reinforces the health education received from nurses or doctors during clinic visits. During the pilot, PLWD enjoyed the home visits by CHWs. However, the visits were stopped after the end of the 14-week follow-up period. A participant remarked:
‘Home visits are good, but they stopped after discharge [
The TIP highlights the need for dedicated diabetes nurses or diabetes educators to support healthcare providers in managing PLWD. The TIP field researchers often played the role of dedicated diabetes nurses or educators that was not sustainable. In the South African public healthcare system, staff rotation and turnover threaten the quality of care given to patients. Dedicated diabetes nurses will promote continuity of care, and they will be able to educate and counsel patients and prepare patients for insulin therapy.
The TIP intervention could be replicated in other parts of South Africa and in other resource-constrained settings. The TIP intervention fits into the ICDM model adopted by the National Department of Health to achieve optimal outcomes for patients with chronic communicable and non-communicable diseases. There is a large pool of insulin-requiring T2DM patients who would benefit from the TIP intervention, and PLWD who have already been initiated on insulin could provide peer support to those patients. The dissemination of the TIP intervention was supported by health professionals involved in the pilot:
‘I wish it can [
During the pilot study, a number of patients refused to start insulin despite being encouraged to do so by healthcare providers. Insulin resistance was common amongst PLWD, and negative attitudes towards insulin may have been fuelled by family or community misconceptions about insulin. This was corroborated by a health professional:
‘Most of the patients have fear of starting insulin.’ (Participant 2, female, nurse)
Some healthcare providers failed to take ownership of the intervention because they believed that it was not their duty to complete the prescribed tasks, even though initiating patients on insulin is their responsibility according to the guidelines for the management of diabetes in primary care. At times, healthcare providers relied heavily on TIP field researchers to complete certain tasks. Such attitudes threatened the sustainability of the TIP intervention. A nurse commented:
‘Having TIP people like
Additionally, the successful use of telehealth requires doctors to be available on the mobile app when the nurses need to reach them. Not being available is a threat to the TIP. Nurses could not always reach doctors timeously, resulting in frustration whilst waiting for a doctor to respond, which also meant a longer consultation time for the patient. A nurse explained:
‘When the clinic doctor was unavailable it was difficult to get hold of family doctor [
In South Africa, primary healthcare workers routinely deal with high patient volumes and a quadruple burden of disease. These factors have been shown to result in short consultation times, lack of dedicated staff for patient education and the pressure to see patients quickly and have also been identified as barriers to insulin initiation. In this context, providers may hesitate to implement the TIP intervention as demonstrated by the following quote:
‘I would suggest that because the programme has its own clinicians they can be able to initiate and manage patients to reduce lot of work for clinic nurses.’ (Participant 13, female, nurse)
Participants identified a number of health system factors as potential threats to the implementation of the TIP intervention. Those included poor filing and data systems, incomplete or unreliable patient records which make patient identification difficult and cumbersome; limited resources including a shortage of insulin or needles and competing priorities at primary care facilities.
After gathering data according to the SWOT categories recorded in
Strengths, weakness, opportunities and threat analysis strategies to improve the implementation of the Tshwane Insulin Project intervention.
SO strategies | WO strategies |
---|---|
1. Replicate the TIP intervention to respond to the existing large pool of insulin-requiring PLWD at primary care facilities and avoid unnecessary referrals for insulin initiation. | 1. Translate the education materials to improve accessibility by PLWD and improve health literacy. |
2. Promote the use of simplified protocols and processes to improve healthcare providers’ confidence to initiate insulin safely. | 2. Roll out good quality Wi-Fi at all primary care facilities to enable digital health interventions including the TIP intervention and to resolve issues related to the unavailability of mobile data and network. |
3. Adopt a multidisciplinary care team approach to facilitate insulin initiation and titration and ensure that primary healthcare providers share the workload. | 3. Hire dedicated diabetes nurses or diabetes educators to alleviate providers’ workload and ensure the delivery of good diabetes care including initiation of insulin. |
4. Develop strategies to support insulin-requiring PLWD such as a family on-boarding programme, dramatic plays or informative sessions with insulin-using PLWD. | 4. Involve allied healthcare workers to reduce the pressure on providers by sharing tasks such as patient education and counselling. |
- | 5. Involve WBOT/CHWs in the follow-up of employed patients, explore home visits on weekends. |
TIP, Tshwane Insulin Project; SO, strengths-opportunities; WO, weaknesses-opportunities; PLWD, people living with diabetes; WBOT/CHWs, ward-based outreach team/community health workers.
Strengths, weakness, opportunities and threat analysis strategies to improve the implementation of the Tshwane Insulin Project intervention.
ST strategies | WT strategies |
---|---|
1. Educate PLWD using patients’ lived experiences to combat insulin resistance and advocate for insulin therapy amongst PLWD and in communities. | 1. Educate patients and their families by providing culturally-sensitive education materials, to address community misconceptions and stigma attached to diabetes and insulin. |
2. Strengthen the engagement with stakeholders including healthcare providers to secure their buy-in and improve their adoption of new technologies. | 2. Resolve health workforce challenges as well as issues with mobile data and network to ensure buy-in and participation of healthcare providers. |
3. Procure monitoring equipment and consumables for PLWD to promote insulin initiation in primary care and to avoid discontinuation of insulin therapy. | - |
4. Strengthen the training of healthcare providers to ensure compliance with guidelines and avoid detrimental practices such as the abuse of repeat prescriptions with limited monitoring of PLWD. | - |
ST, strengths-threats; WT, weaknesses-threats; PLWD, people living with diabetes.
Whilst the TIP team may be able to translate educational materials into local languages or educate patients by sharing lived experiences of PLWD initiated on insulin, other strategies will require the commitment and support of the health authorities. For example, the National Department of Health will have to procure monitoring equipment (glucometers and test strips) for all insulin-treated PLWD in primary care. The roll out of good quality Wi-Fi at primary care facilities and the provision of smartphones to health workers is also part of the infrastructure that needs to be provided by health authorities.
The future of diabetes care in resource-constrained settings lies in the decentralisation of care, from experts who work in hospitals to CHWs and other non-clinical providers who work in the primary care system to deliver home-based screening and care enabled by simple and effective information technology solutions.
Our SWOT analysis suggests that, regardless of the identified weaknesses and potential threats, the TIP intervention was accepted by PLWD and healthcare providers involved in the pilot study. According to the participants, the TIP intervention benefitted and improved insulin management for patients with T2DM. People living with diabetes who participated in the TIP were also more knowledgeable about their condition. Insulin-treated PLWD who feel empowered by healthcare providers might have an increased sense of control of their condition and, subsequently, might become more actively involved in disease management, resulting in better glycaemic control.
At the time when insulin is presented as an option, PLWD often experiences insulin distress, defined as an emotional response to the suggested use of insulin characterised by severe apprehension, discomfort, dejection or denial because of a perceived inability to cope with the requirements of insulin therapy.
McGloin et al.
In the pilot study, participants felt that the supply of equipment to monitor blood glucose was particularly helpful. Access to blood glucose monitors and test strips enhance patient education and empowerment,
We identified the negative attitudes of healthcare professionals as a major threat to the TIP intervention. Healthcare professionals are important partners in the implementation of innovative interventions such as the TIP. Therefore, their buy-in and participation are crucial to ensure the success and sustainability of the intervention. Addressing their concerns of a perceived increased workload and lack of time should be a priority. Involving health promoters and hiring dedicated diabetes nurses or diabetes educators could allow healthcare professionals to focus specifically on clinical tasks, reducing their workload. Task sharing has been successfully implemented in South Africa in the human immunodeficiency virus (HIV) programme,
The SWOT analysis resulted in 15 strategies to improve the implementation of the TIP intervention, making it more sustainable. The low-hanging fruits include translating education materials into local languages, developing a strategy to follow-up employed patients and using the lived experiences of insulin-treated patients to address insulin resistance and advocate for insulin therapy amongst PLWD and in communities. Our ultimate aim is to integrate the TIP into primary care across South Africa. To achieve this, the TIP will have to be adopted into national health plans and facilities, garnering a portion of the health budget. An initial investment will result in long-term gains for diabetes management in South Africa.
Subjectivity and unilateralism are amongst the common limitations of a SWOT analysis as the people who determine the factors falling into the four SWOT categories may be too involved to be objective.
The SWOT analysis provided insights on the strengths of the TIP intervention and that strategies could facilitate implementation and dissemination of the TIP intervention. The analysis painted an overall picture of the complexity of implementing innovative health interventions in settings where resources are limited. Lessons learnt from this exercise will assist decision-makers and health researchers in resource-constrained settings who seek to improve insulin management for PLWD in primary care using community-oriented telehealth interventions.
The authors would like to thank the healthcare workers and people living with diabetes who participated in this study, Prof Paola Wood for reviewing the manuscript and Dr Cheryl Tosh for editing the manuscript.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
P.N.P. conceptualised and designed the study, analysed qualitative data, drafted the manuscript. C.F. contributed to the conception or design of the work, organised and facilitated the focus group, drafted the manuscript. M.G.M., N.Z., A.S., C.K. contributed to the SWOT analysis and drafting the article. J.W.M. contributed to the conception or design of the work and revised the manuscript. E.W.M. contributed to the conception or design of the work, contributed to the SWOT analysis and revised the manuscript. P.R. contributed to the conception or design of the work and revised the manuscript. P.N.P. and C.F. are also responsible for the overall content as guarantors. All authors approved the final manuscript.
This work was supported by the Lilly Global Health Partnership (Project Grant: A1B004/04408). The funder was not involved in the choice of study design; in the collection, analysis and interpretation of data; in the writing of the report and in the decision to submit an article for publication.
The data that support the findings of this study are available from the corresponding author, P.N.P., upon reasonable request.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors and the publisher.