The sustainability of group empowerment and training for people with diabetes in South Africa

BACKGROUND

 Group empowerment and training (GREAT) for people with type 2 diabetes enables self-management and lifestyle modification. GREAT for diabetes was implemented in primary care facilities in five South African provinces in the beginning of 2022. The aim was to evaluate implementation and to particularly explore factors that influenced the sustainability of implementation.

METHODS

 An exploratory, descriptive qualitative study conducted semi-structured individual interviews with 17 key stakeholders at the end of 2023. Interviews explored factors within a theory of change framework derived from an initial evaluation in 2022. Data were analysed using the framework method and ATLAS.ti.

RESULTS

 Implementation and scale-up was sustained in the Western Cape. Governance and financing at a provincial and district level were key to health system structures. Space, staffing, resource materials and monitoring of implementation were key to the inputs. Facility managers, training and performance of facilitators, including the whole team, selecting patients, patient flow and appointments, stakeholder support and clinical governance were key to service delivery. Facilities that had implemented, reported reaching 300 patients per year. A range of motivational, behavioural and clinical outcomes were reported. Future implementation could include community health workers and group empowerment for insulin initiation.

CONCLUSION

 Implementation and scale-up was only sustained in one province and a range of factors related to sustained implementation were identified.Contribution: The factors identified can guide the successful implementation and scale-up of GREAT for diabetes in South Africa.

Digital Health Solutions for Community-Based Control of Diabetes During COVID-19 Pandemic: A Scoping Review of Implementation Outcomes

BACKGROUND

The COVID-19 pandemic has added to the pre-existing challenges of diabetes management in many countries. It has accelerated the wider use of digital health solutions which have tremendous potential to improve health outcomes for people with diabetes. However, little is known about the attributes and the implementation of these solutions.

OBJECTIVE

To identify and describe digital health solutions for community-based diabetes management and to highlight their key implementation outcomes.

METHODS

We searched Ovid Medline, CINAHL, Embase, PsycINFO, and Web of Science for relevant articles. A purposive search was also used to identify grey literature. Articles that described digital health solutions that aimed to improve community-based diabetes management were included in this review. We applied a thematic synthesis of evidence to describe the characteristics of digital health solutions, and to summarize their key implementation outcomes.

RESULTS

We included 15 articles that reported digital health solutions that primarily focused on community-based diabetes management. Nine of the 15 innovations involved were mobile applications and/or web-based platforms, and five were based on social media platforms. The majority of the digital health solutions were used for diabetes education and support. High engagement, utilization, and satisfaction rates with digital health solutions were observed. The use of digital health solutions was also associated with improvement in self-management, taking medication, and reduction in glycated hemoglobin (HbA1c) levels.

CONCLUSION

COVID-19 triggered digital health solutions have tremendous potential to improve health outcomes for people with diabetes. Further studies are needed to evaluate the sustainability and scale-up of these solutions.

Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries: protocol for a longitudinal mixed-methods study

INTRODUCTION

There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions.

METHODS AND ANALYSIS

We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TP and conduct multistakeholder qualitative interviews to gather data at T0 and T1. We will undertake descriptive statistical analysis of TP data and analyse T0 and T1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks.

ETHICS AND DISSEMINATION

The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network.

Evaluating the implementation of the GREAT4Diabetes WhatsApp Chatbot to educate people with type-2 diabetes in Cape Town during the coronavirus pandemic: Convergent mixed methods (Preprint)

Background

In South Africa, diabetes is a leading cause of morbidity and mortality, which was exacerbated during the COVID-19 pandemic. Most education and counseling activities were stopped during the lockdown, and the GREAT4Diabetes WhatsApp Chatbot was innovated to fill this gap.

Objective

This study aimed to evaluate the implementation of the chatbot in Cape Town, South Africa, between May and October 2021.

Methods

Convergent mixed methods were used to evaluate the implementation outcomes: acceptability, adoption, appropriateness, feasibility, fidelity, cost, coverage, effects, and sustainability. Quantitative data were derived from the chatbot and analyzed using the SPSS. Qualitative data were collected from key informants and analyzed using the framework method assisted by Atlas-ti. The chatbot provided users with 16 voice messages and graphics in English, Afrikaans, or Xhosa. Messages focused on COVID-19 infection and self-management of type 2 diabetes.

Results

The chatbot was adopted by the Metro Health Services to assist people with diabetes who had restricted health care during the lockdown and were at a higher risk of hospitalization and death from COVID-19 infection. The chatbot was disseminated via health care workers in primary care facilities and local nonprofit organizations and via local media and television. Two technical glitches interrupted the dissemination but did not substantially affect user behavior. Minor changes were made to the chatbot to improve its utility. Many patients had access to smartphones and were able to use the chatbot via WhatsApp. Overall, 8158 people connected with the chatbot and 4577 (56.1%) proceeded to listen to the messages, with 12.56% (575/4577) of them listening to all 16 messages, mostly within 32 days. The incremental setup costs were ZAR 255,000 (US $16,876) and operational costs over 6 months were ZAR 462,473 (US $30,607). More than 90% of the users who listened to each message found them useful. Of the 533 who completed the whole program, 351 (71.1%) said they changed their self-management a lot and 87.6% (369/421) were more confident. Most users changed their lifestyles in terms of diet (315/414, 76.1%) and physical activity (222/414, 53.6%). Health care workers also saw benefits to patients and recommended that the service continues. Sustainability of the chatbot will depend on the future policy of the provincial Department of Health toward mobile health and the willingness to contract with Aviro Health. There is the potential to go to scale and include other languages and chronic conditions.

Conclusions

The chatbot shows great potential to complement traditional health care approaches for people with diabetes and assist with more comprehensive patient education. Further research is needed to fully explore the patient’s experience of the chatbot and evaluate its effectiveness in our context.

Evaluating the implementation of home delivery of medication by community health workers during the COVID-19 pandemic in Cape Town, South Africa: a convergent mixed methods study

Background

Primary care services in South Africa have been challenged by increasing numbers of people with communicable and non-communicable chronic diseases. There was a need to develop alternative approaches for stable patients to access medication. With the onset of the coronavirus pandemic there was an urgent need to decongest facilities and protect people from infection. In this crisis the Metro Health Services rapidly implemented home delivery of medication by community health workers. This study aimed to evaluate the implementation of home delivery of medication by community health workers during the coronavirus pandemic in Cape Town, South Africa.

Methods

A convergent mixed methods study evaluated six implementation outcomes: adoption, feasibility, fidelity, coverage, cost, and sustainability of the initiative. Data sources included routinely collected data, a telephonic survey of 138 patients, an analysis of set-up and recurrent costs as well as 17 descriptive exploratory qualitative semi-structured interviews with 68 key informants.

Results

Over a 6-month period 1,054,657 pre-packaged parcels were sent to primary care facilities, 819,649 (77.7%) were delivered and of those 97,297 (11.9%) returned. The additional costs were estimated as 1.3% of a total health budget of R2,2 billion. The initiative was rapidly adopted as it decongested facilities and protected vulnerable patients. Although it was feasible to implement at scale, numerous challenges were encountered, such as incorrect addresses and contact details, transporting parcels, communicating with patients, having a reliable audit trail, and handling out-of-area patients. All role players thought the service should continue and 42.3% of patients reported better adherence to their medication.

Conclusion

Home delivery of medication by community health workers is feasible at scale and affordable. It should continue, but as one of a menu of options for alternative delivery of medication. The following need to be improved: efficiency of the system, the audit trail, adequate support and resources for community health workers, transport of medication, communication with patients, empanelment of patients, governance of the system and training of the community health workers.

Non-communicable disease care and management in two sites of the Cape Town Metro during the first wave of COVID-19: A rapid appraisal

Background

Non-communicable diseases (NCDs), including type-2 diabetes and hypertension, have been associated with increased morbidity and mortality rates because of coronavirus disease 2019 (COVID-19). Maintaining quality care for these conditions is important but data on the impact of COVID-19 on NCD care in South Africa are sparse.

Aim

This study aimed to assess the impact of COVID-19 on facility and community-based NCD care and management during the first COVID-19 wave.

Setting

Two public health sector primary care sites in the Cape Town Metro, including a Community Orientated Primary Care (COPC) learning site.

Methods

A rapid appraisal with convergent mixed-methods design, including semi-structured interviews with facility and community health workers (CHWs) (n = 20) and patients living with NCDs (n = 8), was used. Interviews were conducted in English and Afrikaans by qualified interviewers. Transcripts were analysed by thematic content analysis. Quantitative data of health facility attendance, chronic dispensing unit (CDU) prescriptions and routine diabetes control were sourced from the Provincial Health Data Centre and analysed descriptively.

Results

Qualitative analysis revealed three themes: disruption (cancellation of services, fear of infection, stress and anxiety), service reorganisation (communication, home delivery of medication, CHW scope of work, risk stratification and change management) and outcomes (workload and morale, stigma, appreciation and impact on NCD control). There was a drop in primary care attendance and an increase in CDU prescriptions and uncontrolled diabetes.

Conclusion

This study described the service disruption together with rapid reorganisation and change management at primary care level during the first COVID-19 wave. The changes were strengthened by the COPC foundation in one of the study sites. The impact of COVID-19 on primary-level NCD care and management requires more investigation.

Changes in risk factors for non-communicable diseases associated with the 'Healthy choices at work' programme, South Africa

BACKGROUND

Globally 71% of deaths are attributed to non-communicable diseases (NCD). The workplace is an opportune setting for health promotion programs and interventions that aim to prevent NCDs. However, much of the current evidence is from high-income countries.

OBJECTIVE

The aim of this study was to evaluate changes in NCD risk factors, associated with the Healthy Choices at Work programme (HCWP), at a commercial power plant in South Africa.

METHODS

This was a before-and-after study in a randomly selected sample of 156 employees at baseline and 137 employees at 2-years. The HCWP focused on food services, physical activity, health and wellness services and managerial support. Participants completed questionnaires on tobacco smoking, harmful alcohol use, fruit and vegetable intake, physical activity, psychosocial stress and history of NCDs. Clinical measures included blood pressure, total cholesterol, random blood glucose, body mass index, waist circumference and waist-to-hip ratio. The 10-year cardiovascular risk was calculated using a validated algorithm. Sample size calculations evaluated the power of the sample to detect meaningful changes in risk factors.

RESULTS

Paired data was obtained for 137 employees, the mean age was 42.7 years (SD 9.7) and 64% were male. The prevalence of sufficient fruit and vegetable intake increased from 27% to 64% (p < 0.001), those meeting physical activity guidelines increased from 44% to 65% (p < 0.001). Harmful alcohol use decreased from 21% to 5% (p = 0.001). There were clinical and statistically significant improvements in systolic and diastolic blood pressure (mean difference -10.2 mmHg (95%CI: -7.3 to -13.2); and -3.9 mmHg (95%CI: -1.8 to -5.8); p < 0.001) and total cholesterol (mean difference -0.45 mmol/l (-0.3 to -0.6)). There were no significant improvements in BMI. Psychosocial stress from relationships with colleagues, personal finances, and personal health improved significantly. The cardiovascular risk score decreased by 4.5% (> 0.05).

CONCLUSION

The HCWP was associated with clinically significant reductions in behavioural, metabolic and psychosocial risk factors for NCDs.

Transforming the workplace environment to prevent non-communicable chronic diseases: participatory action research in a South African power plant

Background: The workplace is an important setting for the prevention of non-communicable diseases (NCDs). Policies for transformation of the workplace environment for occupational health and safety in South Africa have focused more on what to do and less on how to do it. There are no guidelines and little evidence on workplace-based interventions for NCDs.

Objective: The aim of this study was to learn how to transform the workplace environment in order to prevent and control cardio-metabolic risk factors for NCDs amongst the workforce at a commercial power plant in Cape Town, South Africa.

Methods: The study design utilized participatory action research in the format of a cooperative inquiry group (CIG). The researcher and participants engaged in a cyclical process of planning, action, observation and reflection over a two-year period. The group used outcome mapping to define the vision, mission, boundary partners, outcomes and strategies required. At the end of the inquiry the CIG reached a consensus on their key learning.

Results: Substantial change was observed in the boundary partners: catering services (78% of progress markers achieved), sport and physical activities (75%), health and wellness services (66%) and managerial support (65%). Highlights from a 10-point consensus on key learning included the need for: authentic leadership; diverse composition and functioning of the CIG; value of outcome mapping; importance of managerial engagement in personal and organizational change; and making healthy lifestyle an easy choice.

Conclusion: Transformation included a multifaceted approach and an engagement with the organization as a living system. Future studies will evaluate changes in the risk profile of the workforce, as well as the costs and consequences for the organization.