December 8, 2022

Editor-in-Chief of the African Journal of Primary Health Care & Family Medicine (PHCFM), Professor Robert Mash, interviews one of the co-authors, Patrick Ngassa Piotie, on the recent article published in the scholarly journal.

Great so um i’m here today with uh patrick piotti who’s the first author of a original research article called factors affecting the implementation of a complex health intervention to improve insulin management in primary care which was done in south africa um and he he and i are going to have a brief conversation about the findings and the implications of of

This piece of work so um patrick before we start can you um tell us a little bit about yourself i mean who actually are you and what are you doing yes thanks bob uh my name is patel nassarpurtier i’m a researcher from cameroon based in south africa for a number of years now um i’m at the university of victoria at the university of virginia diabetes success

Center my background is medical doctor but for the past 10 years i’ve been focusing on public health having completed a master’s in public health and i’m currently completing my phd my main interests for the past few years have been diabetes mostly in terms of improving outcomes and having an influence so that people with that diabetes in general can have

A better life great thanks so now what is it about um diabetes and primary care and insulin that led you to feel that this study was was needed with the the chimpanzees led by provider there’s been some some research done previously especially in the sunny district and the research that we conducted about uh almost 10 years ago now show that people with

Type 2 diabetes in primary care who were doing the worst in terms of diabetes outcome where either those were in need of insulin or those who were already on incident obviously in the primary care sector in south africa a patient with their diabetes start with one third and then they are moved with a second birth and then the option of israel is available and

The good news is available for faith in south africa unfortunately for various factors either patient related health care provider related or system related there is that resistance to transition from over drugs to insulin and if that needs obviously to poor outcome from people living with diabetes so that was basically the motivation for us to come here with

A transitional research program and to try to to change the picture great so now i know that that you and your team and and uh and paul ryder i know him a little bit you you set up this uh schwann a insulin project or tip uh as you uh as as it’s called so what actually is it what does it involve the uh schweine insulin project intervention i will share some

Sketch share a slide with us okay so our 2017 project we’ve started in 2018 we’re working with our partner the founder and i should disclose being really global health partnership but we’re working closely with the health authorities mainly how they provide city of sunny as well as the strategies to the local authorities our goal was to make sure that we have an

Intervention that will be sustainable and that can fit into the health system as it is in primary care so the team of a researcher from university of petroya we had family people from family medicine people from internal medicine people from sports sciences nursing as well as the school of health system and public health they come together after conducting some

Baseline surveys and and and audits we realize that we need to have a multi-layered type of intervention that way we came up with the swani insulin project intervention without getting too much into the details the beauty of that intervention is that it’s an integrated community-based person-centered intervention what we mean by that is that the person living

With diabetes is at all level the priority in that intervention the innovation that we have here is that when a person with type 2 diabetes is identified and initiated on insulin their follow-up is not only limited to the monthly clinic visits we have introduced home visits which are done on a weekly basis so the committee of worker and the warped world-based

Average team it is involved here to ensure a good follow-up of those patients as you are aware of the good challenges one of the great challenges insulin is titration in the public system at the moment that direction happens on a monthly visit when the patient goes to the clinic but with our intervention and bringing in the medicine the titration can happen on

A weekly basis meaning the patient reach quicker and optimal and insulin dose and is controlled quicker that’s in a nutshell the beauty of this intervention and that’s what we’ve been implementing for the past two years in the 20th district in south africa so i see that on your slide you you talk about an app-enabled physician to help with that adjustment of

The dose of insulin um what how did that work just very briefly i think if i remember from the article you’re using the vula app yes so we give to our patient obviously because to control the blood sugar they have also a diary where they not the values we recommend that they need to test at least twice a day and in the morning before breakfast and what once

In the during the day after one of the big meal they keep their diary with their values on it when the community of workers visit at the home they have the opportunity to take a picture of the values and using fuller to send them to the physician who might be located in the cadet clinic or anywhere else definition assess the values and can give the instruction

To the community worker to increase or decrease the dose of insulin by two units the challenge that we identified is that in the the guidelines in south africa the doctor or the family physician should is recommended to train the patient on how to directly unfortunately our patients most of the time are either without the numeracy skills necessary or without the

Health literacy necessary so basically that direction never happens the self-titration as recommended with using the commit chef worker we are adding that additional support that ensure that when the doctors relay the message to the committee worker the committee is present with the doctor the patient and can show how much more the insulin they can they should

Increase the doses before doing the inject okay no thank you so um moving on to the to the research so what actually was the aim of your research and and what in very very you know sentence or two what was your study design what how did you go about the methods so once we designed the intervention we piloted it in a few facilities about 10 primary care facilities

Because our motivation has been to ensure that the intervention is sustainable and scalable we decided to take a moment to reflect we use a model which is a swot analysis whereby we reflect on the strength the weaknesses opportunities and threats of the intervention as it was piloted in order to come up with strategies that will improve its implementation so

The way we did it we had two groups the people were involved into the implementation from this the project side we call them our field workers they did a focused group discussion reflecting on the intervention we also spoke to the doctor the nurses and the patients who were involved in that uh receiving that intervention regarding looking at the the stress the

Weaknesses the benefit and the disadvantage that they identified and that’s what that’s our that was our study so they’re coming to the meat of the thing then uh what actually were the strengths and the weaknesses and the opportunities and the threats what what were the key things that you found uh when you evaluated the the model one of the key points that

Came up as a strength was that model of proactive follow-up as i describe it not only the monthly visit but also the weekly home visit the patient really responded positively we do not follow up because they felt that they were not alone anymore all that information that they received on the first day they didn’t have to stress somebody was who was coming along

On a weekly basis to remind them and to support them with that another strength that we identified was the fact that we were providing glucose machine and test trip to the patient which was not the case in the public sector at the time when we started the intervention i should also analyze that the field workers that we had really played a big hole not only in

Supporting the patient but also in providing technical assistance to the healthcare provider with on-site job training so those were really some of the strengths in the intervention the weakness that we identify where that the materials unfortunately that we developed were in english so the patients couldn’t really take full advantage of those education material

That we provided and that was noted but also the reliance on smartphone on and the availability of a network as you can imagine if an app is involved that means somebody must have network and sometimes in south africa in the territory we don’t have a future the distribution of the network so from time to time the the healthcare provider whether at the clinic or

At the home of the patient were penalized also because sometimes the doctor were not always close to the phone to respond to the message that was coming in in instantaneously but when it comes to the opportunities one of the key opportunities that we identify here was the involvement of allied care workers in diabetes care namely your community chef worker who

Could be trained and play a role to to link the home and the facility and the family physician that was quite beautiful but we also saw that if we continue like that maybe training help promoters and all the alarm care worker that could lead to that sharing because in south africa our nurses and doctors are quite overburdened we cannot rely on nerves on them only

To fulfill all the tasks that they have to fulfill so having those highlighted workers was very helpful one of the key threats unfortunately that i have to note is that there is a quite a prevalent insulin resistance in south africa especially in the communities among the patients but also among the healthcare providers and it’s really for education and and and

And mobilization that we can have in that form so it’s quite interesting what you’re saying i mean like there’s a two or three things that maybe we can briefly touch on uh the one of course interesting thing is okay so you’ve involved the community health workers uh in this and uh and i note that of course they’re essentially like then using the app to get input

From the family physician or the doctor um i mean how um how realistic is it to expect community health workers to to actively support the initiation of insulin it’s quite a sort of complicated isn’t it um sort of medical thing you know injections and dosages and you know understanding when you have to give it where you have to give it and all of this um do

You think the community health workers i mean did were they able to really support all of that um and i suppose linked to that before you watch that is of course the community health workers they also have a usually a nurse a professional nurse or a nurse anyway that is kind of leading their team was there a role for the nurse in all of this as well yeah indeed

That’s a very good question paul we limited the role to non-clinical duties the initiation in itself was done by the doctor and the nurse at the clinic what they were managed to do was not only to support the education message that the patient received in terms of injection sites in terms of injection technique in terms of how to measure and because meter we

Found that when they are properly trained these are tasks that they can easily do now when it comes to the average generator that’s registered that you mentioned with her whole came in mostly when it was about titration to be on the safe side we decided that those visits at home when titration of insulin would be necessary were conducted mainly by the registered

Nurse which is the outreach team leader obviously it might bring some limitation because there’s only one per team and but as we found there were some cases where she wasn’t available and one of her team members could do it as i discussed is just about taking a picture sending it to the doctor and the doctor made the clinical decision to say instruct the patient

To increase or decrease and the communication worker has the capacity to show using the valve to the patient how it should be increase or decrease so technically their role was really more on the educational side and to support that tradition using the the the the the vula limiting really the outside of the clinical duties so so the the final question i had which

Relates more to the facility-based sort of aspects of of the intervention you know where you said of course that the the the doctor and the nurse were like responsible for initiating and starting this whole process um and i noticed in the in the uh article that you know you the the tip project provided sort of additional assistance you know field workers or

Whatever in the clinic um they ended up maybe you know being essentially uh providing additional capacity in the clinic to to do the things there that were necessary to kind of get the whole process started so i suppose my question was if you take away your field workers uh how sustainable would the project be if you were just relying on the usual resources

That were available in the clinic um or does it require this sort of extra input so in unfairness this this is a valid question our field worker played a big hole when he came to supporting the identification of people with type 2 diabetes who required to go in insulin they also assisted when it came to that first education session before initiation because

It’s quite a heavy uh thing to do in terms of teaching the patient how to inject and when to inject and all that in average it might take 45 to 1 hour only for that education yes our concern has been that once you remove the cheap cheap field worker the whole thing might collapse but we really work closely with the nurse and the doctor to say first we train them

They know now how to identify and what they need to do we comforted them that this is not an exercise that they will have to do every day once in a while they might have to spend one hour on this patient so that the care is improved so one you if that is basically about when we put it in the the paper the attitude of health care providers was identified as one

Of the threats some of them really took on the project and became active participants others had that attitude to say no these are project duties although based on the guidelines initiating and following up patients is their responsibility but there was this article that we have to struggle on bottom line is if they really take on the project they are able to

Identify them train them educate them and follow them up we didn’t really add more to what they are usually required to do so patrick we probably have to end just now um is there a final point that you want to make in terms of the implications of your work something that we didn’t mention but is important to to maybe just uh have as a last point the lord of

The health authorities obviously in supporting this type of research translational uh diabetes research is very important that support because if obviously we come from the university we cannot give instructions or order to the the people on the ground and as well as when we are trying to do something different something new innovative for example by including

The committee of worker in that that process is the health authorities who should sometimes take on that hole to not only see the vision and the the what you are trying to achieve so that they can be the one instructing the the staff their support is very important in realizing what you are trying to achieve and achieving would not yes so implementing you know

In a strong collaborative way with with the actual health services yes i can totally get that so patrick thank you very much for telling us about uh the schwanna insulin project and the and the study that you’ve published in the primary healthcare family medicine journal and we look forward to hearing more about the outcomes from this project in the future thank

You paul thank you very much for having me thanks

Transcribed from video
How to improve insulin management for PLWD – PHCFM Article Interview – Prof Robert Mash By AOSIS (Pty) Ltd