Optimizing care and outcomes for people with type 2 diabetes - lessons from a translational research program on insulin initiation in general practice

Designing an integrated, nurse-driven and home-based digital intervention to improve insulin management in under-resourced settings

BACKGROUND

In South Africa, initiating insulin for people with type 2 diabetes and subsequent titration is a major challenge for the resource-constrained healthcare system. Inadequate support systems in primary care, including not being able to access blood glucose monitors and test strips for self-monitoring of blood glucose, results in patients with type 2 diabetes being referred to higher levels of care. In primary care, initiation of insulin may be delayed due to a shortage of healthcare workers. The delayed initiation of insulin is also exacerbated by the reported resistance of both healthcare providers and people with type 2 diabetes to start insulin. In South Africa, telehealth provides an opportunity to overcome these challenges and manage insulin therapy in primary care.

METHODS

We describe the development of a digital health intervention including the framework used, the theoretical approach and subsequent implementation strategies.

RESULTS

This intervention is an innovative, nurse-driven and app-enabled intervention called 'the Tshwane Insulin Project intervention'. The Tshwane Insulin Project intervention was designed and evaluated using the framework recommended by the Medical Research Council for complex interventions. The Tshwane Insulin Project intervention was developed in four sequential phases: planning, design, implementation and evaluation. The Tshwane Insulin Project intervention followed the Integrated Chronic Disease Management framework to facilitate implementation and acceptability. The Tshwane Insulin Project comprises a facility-level intervention, where nurses evaluate patients and initiate insulin, an individual-level intervention where community healthcare workers visit patients at their homes to follow-up and provide educational information, while using telehealth to enable physician-directed insulin titration if needed, and a community-level intervention aimed at empowering community healthcare workers to support people living with diabetes and raise awareness of diabetes.

CONCLUSION

The technological advancements in digital health and telemedicine present an opportunity to improve diabetes care in resource-limited countries. This work can inform those intending to develop and implement complex interventions in primary healthcare in developing countries.

Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review

BACKGROUND

Normalization Process Theory (NPT) identifies, characterises and explains key mechanisms that promote and inhibit the implementation, embedding and integration of new health techniques, technologies and other complex interventions. A large body of literature that employs NPT to inform feasibility studies and process evaluations of complex healthcare interventions has now emerged. The aims of this review were to review this literature; to identify and characterise the uses and limits of NPT in research on the implementation and integration of healthcare interventions; and to explore NPT's contribution to understanding the dynamics of these processes.

METHODS

A qualitative systematic review was conducted. We searched Web of Science, Scopus and Google Scholar for articles with empirical data in peer-reviewed journals that cited either key papers presenting and developing NPT, or the NPT Online Toolkit ( www.normalizationprocess.org ). We included in the review only articles that used NPT as the primary approach to collection, analysis or reporting of data in studies of the implementation of healthcare techniques, technologies or other interventions. A structured data extraction instrument was used, and data were analysed qualitatively.

RESULTS

Searches revealed 3322 citations. We show that after eliminating 2337 duplicates and broken or junk URLs, 985 were screened as titles and abstracts. Of these, 101 were excluded because they did not fit the inclusion criteria for the review. This left 884 articles for full-text screening. Of these, 754 did not fit the inclusion criteria for the review. This left 130 papers presenting results from 108 identifiable studies to be included in the review. NPT appears to provide researchers and practitioners with a conceptual vocabulary for rigorous studies of implementation processes. It identifies, characterises and explains empirically identifiable mechanisms that motivate and shape implementation processes. Taken together, these mean that analyses using NPT can effectively assist in the explanation of the success or failure of specific implementation projects. Ten percent of papers included critiques of some aspect of NPT, with those that did mainly focusing on its terminology. However, two studies critiqued NPT emphasis on agency, and one study critiqued NPT for its normative focus.

CONCLUSIONS

This review demonstrates that researchers found NPT useful and applied it across a wide range of interventions. It has been effectively used to aid intervention development and implementation planning as well as evaluating and understanding implementation processes themselves. In particular, NPT appears to have offered a valuable set of conceptual tools to aid understanding of implementation as a dynamic process.

Psychosocial Risk Factors, Interventions, and Comorbidity in Patients with Non-Specific Low Back Pain in Primary Care: Need for Comprehensive and Patient-Centered Care

Non-specific low back pain (LBP) affects many people and has major socio-economic consequences. Traditional therapeutic strategies, mainly focused on biomechanical factors, have had moderate and short-term impact. Certain psychosocial factors have been linked to poor prognosis of LBP and they are increasingly considered as promising targets for management of LBP. Primary health care providers (HCPs) are involved in most of the management of people with LBP and they are skilled in providing comprehensive care, including consideration of psychosocial dimensions. This review aims to discuss three pieces of recent research focusing on psychosocial issues in LBP patients in primary care. In the first systematic review, the patients' or HCPs' overall judgment about the likely evolution of LBP was the factor most strongly linked to poor outcome, with predictive validity similar to that of multidimensional scales. This result may be explained by the implicit aggregation of many prognostic factors underlying this judgment and suggests the relevance of considering the patients from biopsychosocial and longitudinal points of view. The second review showed that most of the interventions targeting psychosocial factors in LBP in primary care have to date focused on the cognitive-behavioral factors, resulting in little impact. It is unlikely that any intervention focusing on a single factor would ever fit the needs of most patients; interventions targeting determinants from several fields (mainly psychosocial, biomechanical, and occupational) may be more relevant. Should multiple stakeholders be involved in such interventions, enhanced interprofessional collaboration would be critical to ensure the delivery of coordinated care. Finally, in the third study, the prevalence of psychosocial comorbidity in chronic LBP patients was not found to be significantly higher than in other patients consulting in primary care. Rather than specifically screening for psychosocial conditions, this suggests taking into account any potential comorbidity in patients with chronic LBP, as in other patients. All these results support the adoption of a more comprehensive and patient-centered approach when dealing with patients with LBP in primary care. As this condition is illustrative of many situations encountered in primary care, the strategies proposed here may benefit most patients consulting in this setting.