Diabetes education research: March 2020

Sweet Life is South Africa’s diabetes community: a space to share information and advice about living well with diabetes, both here on the website and on Diabetic South Africans. But we’re also involved in diabetes education research – a big focus for 2020. Each month, we’ll be sharing the research we’ve done into diabetes education in public clinics, in the hopes that it helps someone else looking for answers to diabetic questions! This is the March report, be sure to scroll to the bottom of the page for the other months.

March focus:

To connect with the last few people who have been working in diabetes education research in SA, and consolidate the information. To get a clearer picture of the way forward in terms of what is necessary to turn this theory into practice, alongside the National Department of Health (NDoH) working group.

Relevant diabetes research:

Recent diabetes information

South Africa Demographic and Health Survey 2016

Just released at the end of 2019. Terrifying stats on prediabetes.

• Diabetes: 13% of women and 8% of men have an adjusted HbA1c level of 6.5% or above, indicating that they are diabetic. Most women (64%) and men (66%) have an adjusted HbA1c measurement between 5.7% and 6.4% and are therefore classified as pre-diabetic.

64% of SA women and 66% of SA men are prediabetic!!

• The prevalence of diabetes in women and men based on self-reports (5% and 4%, respectively) presented in Table 16.2 is lower than the prevalence indicated by HbA1c testing. Among those who have never been diagnosed with diabetes, 10% of women and 6% of men have adjusted HbA1c levels indicating that they are diabetic; 67% of both women and men who reported that they were never diagnosed with diabetes have adjusted HbA1c levels indicating that they are pre-diabetic. Thus, a large proportion of adults are either not aware of their condition or not aware that they are at risk for diabetes.

Sweet Life prepared a press release about prediabetes following the stats from the Allegra data we were given from November 2019 (Clicks, Dis-Chem and AlphaPharm voluntary testing showed that 35% of readings were prediabetic). We have put this press release on pause till after COVID-19. We can now support it with this much larger data set.

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Interviews:

NOD: Nurses on Diabetes training by Roche (Belinda Lister)

• Established years ago (2012), developed with a board of experts. The whole approach is around training nurses in coaching skills – soft skills needed to coach patients with diabetes. Patient-centered approach, very different method of dealing with a patient vs a patient who has high blood pressure. Requires collaboration and involvement of patient. Quite a lot of private sector taken on.
• Besides the fact that there’s coaching skills lacking among nurses, also clinical skills lacking. Mixture of skills, but with coaching woven in.
• Current status on the project was lack of scale – taught a lot of the nurses through face to face workshops, generally 3 day or 2 day workshops. What we’ve been working on is a programme to offer NOD but in a way that we can build scale and drive throughout Africa.
• Possibly with a company called URUP – mobile platform that can deliver content education in a way that doesn’t use data.
• Started taking NOD materials and putting it onto this mobile platform.
• Need to partner with an accreditation body so it’s more compelling – possibly the SEMDSA course.
• Targeted nurses working in diabetes, feedback always really positive, face to face and out of the office. Within the public sector, one or two state nurses join us – you can see the difference between private and public sector. 
• Aimed at the same people as the SEMDSA course, clinical content from SEMDSA and coaching from NOD. Quite basic diabetes information – purely nurse aimed. CPD points from doing it online.

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GREAT diabetes session: Symphony Way Clinic

I attended a fascinating session teaching the GREAT (Group Empowerment and Training) approach to diabetes. This was session 1 of 2, and covered what diabetes is, diabetes myths and food choices.

Impressions:

• A wonderful facilitator (Joy) who seemed to really connect with the people there (8 to 10 in the group, all from the surrounding area, speaking a mix of Afrikaans, English and Xhosa).
• Very helpful to have the illustrated flipboard and diabetes information so clearly laid out.
• A nice mix of teaching style and interactive – she came across as informed but also pulled out a lot of personal information and interaction from the group.

Questions:

• There was a lot of emphasis on how insulin works in the body, and how the ‘keys’ of insulin unlock the ‘doors’ of the cells so that sugar can pass through. It seemed quite detailed and involved, and I question how much of it was really understood (or necessary). I don’t know the answer to this: is it necessary to understand how diabetes works in the body to better control your diabetes?
• The myths were very helpful to discuss but provided a confusing grey area in some instances. “If you have diabetes, you have to cook a special meal for yourself” for example. The answer was “False: the whole family should eat how you eat” which is a good point, but perhaps an interim answer is that you have to change the way you eat first, and then bring the whole family along. Similarly, “Diabetics can’t eat bananas and grapes” was said to be “False: diabetics can eat fruit.” Which is true, but without mentioning portion control it is also misleading and unhelpful (10 grapes is the portion size for 1 unit of carb (15g) which is very difficult to stick to). At this level – first interaction with diabetes education – perhaps only the basics should be addressed, rather than nuances?

Common foods for people with diabetes

• There was a really helpful exercise where people chose cards (with photos and names) of the common food they ate, and then had to sort the cards into piles – starch (carbs), protein, fruit, veg, fats and snacks. I honestly thought it was going to be too easy, because the cards were colour coded (all carbs were brown background, all veg was green etc) but it was a real challenge for people. 
• This was the biggest eye-opener! We’ve been preaching messages of eating healthy food and reducing refined carbs and what 15g carb portions look like, and one (well spoken and engaged) man had a ‘bread’ card in his hand, looked at a row of pasta, rice and samp and didn’t know where to put it. Clearly there is a real need for the most basic food education to help manage diabetes.
• This could be in the format of a poster or small booklet (like the SASSI sustainable fish booklet) that outlines all the common foods that fit into each category: all the starches (not just a representative list, as this clearly doesn’t work) and portion sizes (potentially in ‘block’ format). Probably illustrated. PnP wants to do a print project this year, so this could fit in well with that.

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Sebastian Thompson: Behavioural Scientist (Lake Innovation)

There is potential to develop a WhatsApp / mobile based application with Praekelt. Do we go this angle or suggest a print product to NDoH?

• Take this opportunity to work with NDoH and create something lasting: something that will continue to be relevant in the future. Don’t just create something that works for now. Print can be an aspect but it has to be a digital solution.
• We know that people have a lot of questions, we don’t have to prove that. People are coming to Facebook (Diabetic South Africans) because they don’t have answers: they are not being given the diabetes information they need. It’s about scale at the end of the day.
• In an ideal world, every single person would be able to go to a clinic whenever they needed to and get the diabetes information they needed from an expert. That’s never going to happen. 
• How do we take this expertise – the most ideal version of this expert doctor / diabetes educator – and put it in the patient’s hands?
• What we want to see is that instead of people coming to Facebook with their health questions, they ask the app.
• We’re not actually looking for every person who needs to know about diabetes, we’re looking for those who are hungry for diabetes information: pull information not push information.
• So it doesn’t really matter if WhatsApp doesn’t let us push diabetes information repeatedly (the business API has a built-in limit that you can’t keep sending people info to reduce spam). We’re looking for those who want to live healthier but don’t know how.

Challenge: Think about the technological side of DiabetesConnect.

• Is Turn a plug and play solution? If we provide them with the FAQ and the help desk operators, would Praekelt be able to pilot it? Ask more about who the call centre consultants were – what were their previous roles?
• The scope is to replace all the questions on Facebook from recently diagnosed Type 2 diabetics: all those who come to the page to ask this set of questions.
• If we only give this app to people at a clinic who have just been diagnosed with Type 2 diabetes, there’s a consistent path. One entry path: a route to take just diagnosed diabetics and educate how their life needs to change using the TEEL model to improve their outcomes in the first 6 months. 
  
• TEEL model (proposed mnemonic):
  Take medication
  Exercise
  Eat healthy
  Lose weight

The scope:

• How could we create good habits in the first 6 months of being diagnosed with diabetes using our WhatsApp chat tool? Specific habits below that.
• Core journey: what happens in the first week? 
• Feeling sick because of medication – metformin makes you feel worse at first. Take it at the end of the day rather.
• What do I eat now – breakfast / lunch / dinner?
• Testing / eating / medication – think like a computer.
• Pilot in Western Cape 

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Dr Ankia Coetzee: SEMDSA Diabetes Education Initiative

• SEMDSA noticed deficiencies in diabetes education amongst medical doctors and nurses.
• The goal is to develop a diploma in diabetes management – offered at Colleges of Medicine (like the HIV diploma). For all allied health professionals (including dieticians, podiatrists etc).
• This will help to diversify the diabetes educator workforce, and address the increasing demand and access to diabetes education.
• They will aim for HPCSA accreditation and SAQA (NQF) accreditation.

• The proposed SEMDSA course will use an adapted version of the IDF online course (they’re working on the current course with the IDF at the moment). 
• The course would include the 6 month online IDF course with 8 to 10 sessions of Diabetes 101 one day workshops where practical skills are demonstrated.
• There would be three tiers to this diabetes professional course: 1, 2 and 3. Level 1 is the online course, level 2 is the practical sessions, level 3 is fellowship, where you cycle back and mentor the lower levels.

• This is not aimed at community health workers (that is covered by the University of Stellenbosch GREAT project, discussed last month). This is for health professionals of all types: inclusive and open to everyone. 
• It’s also very well priced: R1000 per person for the course so it becomes available to as many people as possible (some pharma are sponsoring large numbers of doctors to do it).

Challenges:

• NDoH needs to help to get nursing council to give accreditation.
• HPCSA contact for registering counsellors similar to HIV counsellors.
• Insulin injection technique – wasting insulin.

Opportunities for collaboration:

• Dr Coetzee is very open to collaboration as she also believes we need to find diabetes solutions that work across South Africa, rather than working in silos.
• I briefly mentioned the idea of a booklet / poster explaining what foods fit into what food groups, and she suggested using the block system to count carbs. Lourentia Van Wyk (dietician at the Western Cape DoH) has developed a system using blocks of carbs and visual representation of what carbs look like. It works very well to explain that you only get a certain number of blocks (carbs) in a day, depending on your nutritional requirements. It becomes an exchange: if you’re putting sugar in your tea (for example), then you’re using up 3 of your blocks and you’ll run out of blocks so you have to give up something else.

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Next steps: April

1. Reach out to Praekelt to get further details on how the app could be developed given this broader scope. Still very exploratory but it would be good to have a clearer picture of what is needed.
2. Create a food list and think through logistics for a PnP booklet / poster of food groups. I’ve reached out to the GREAT team to use theirs but haven’t heard back yet.
3. Read the WHO Be He@lthy Be Mobile handbook for diabetes.

This handbook has been prepared by an international group of experts in mDiabetes for WHO and ITU, to be used by governments, ministries and other relevant national organizations. The main objective of this handbook is to provide evidence-based and operational guidance and resources to assist countries and governments in putting together a detailed work plan for the development and deployment of a national level mDiabetes programme to prevent or control diabetes through healthy living.

The 2020 Diabetes Education Project by Sweet Life is supported by Pick n Pay and BD.

Read the whole diabetes education research series:

• January 2020
• February 2020
• April 2020
• May 2020
• June 2020
• July 2020
• August 2020
• September 2020
• October 2020
• Nov / Dec 2020