A Delphi consensus study to determine the workload components and activity standards of dietitians in South Africa's central and tertiary public hospitals.

BACKGROUND: The global Human Resources for Health (HRH) strategy emphasizes the need to invest in HRH to meet population needs and improve the provision of quality health care services. In South Africa, dietitians are recognized as registered professionals who provide nutrition services. In this paper, we used 2 key steps (3 and 4) of the eight step World Health Organization (WHO) Workload Indicators of Staffing Need (WISN) methodology to determine the workload components and activity standards for dietitians at South African central and tertiary public hospitals. METHODS: All (9) provincial nutrition managers (phase one) and 21 out of a total 22 head dietitians at central and tertiary public hospitals (phase two) participated in an online survey. In phase one, the provincial managers provided the job descriptions (JDs) of dietitians in their provinces, and the JDs were analyzed to determine the baseline workload components. In phase two, dietitians participated in a multi-stage Delphi process to reach consensus on workload components and activity standards. Consensus was deemed to be agreement of 70% or more, while the median of participants' responses was used to obtain consensus on the activity standards. RESULTS: The JDs of dietitians were a useful baseline for the consensus exercise as there were no other suitable source documents. The response rate was 100% for all three rounds of the Delphi survey. Dietitians reached agreement (consensus ≥ 70%) on 92% of proposed workload components and activity standards. Following the removal of duplicate and certain administrative activities, a total of 15 health, 15 support and 15 additional service activities with aligned activity standards resulted from the consensus exercise. CONCLUSION: The Delphi technique was a suitable method for reaching agreement on workload components and activity standards for dietitians at South African central and tertiary public hospitals. The findings from this study can now be used to compile a standardized list of workload components and activity standards and ultimately to determine dietetic staffing needs for the central and tertiary public hospital level of care.

Factors affecting the implementation of a complex health intervention to improve insulin management in primary care: A SWOT analysis.

BACKGROUND:  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. AIM:  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. SETTING:  Tshwane District, Gauteng province, South Africa. METHODS:  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 (n = 13). RESULTS:  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. CONCLUSION:  Our findings may help decision-makers and health researchers to improve insulin management for PLWD in resource-constrained settings by using telehealth interventions.

Assessing barriers to insulin therapy among people with type 2 diabetes in South Africa using the Insulin Treatment Appraisal Scale: A cross-sectional survey.

AIMS: To assess barriers to insulin therapy among people with type 2 diabetes after adapting the Insulin Treatment Appraisal Scale (ITAS) to the South African context. METHODS: A panel of experts reviewed the original ITAS for clarity and relevance to the South African context. The ITAS was administered to 253 adults with type 2 diabetes attending diabetes outpatient clinics in the Tshwane Metropolitan Municipality. Internal consistency (Cronbach's alpha) was tested and construct validity was examined using exploratory factor analysis (EFA). PIR was appraised in insulin users and non-users. RESULTS: The EFA revealed that the adapted ITAS had a two-factor structure, similar to the original scale, with acceptable internal consistency (α = 0.85). Insulin-using participants had significantly less negative attitudes to insulin therapy than non-users (40.7 ± 7.1 vs. 51.5 ± 11.2, p < 0.001). Compared to participants who used insulin, participants who did not use insulin were afraid of injecting themselves with a needle (71% vs. 11%, p < 0.001) and saw insulin treatment as a sign of worsening diabetes (63% vs. 29%, p < 0.001). CONCLUSIONS: Consistent with previous studies, participants who were not using insulin had more negative beliefs and attitudes towards insulin treatment than those who were already using insulin. South African clinicians should use the ITAS to assess positive and negative perceptions regarding insulin therapy in both insulin-naïve and insulin-treated people, to evaluate interventions to reduce PIR and improve treatment outcomes.

Effectiveness of an adapted diabetes nutrition education program on clinical status, dietary behaviors and behavior mediators in adults with type 2 diabetes: a randomized controlled trial.

PURPOSE: This study evaluated the effectiveness of an adapted social-cognitive theory underpinned diabetes nutrition education program (NEP) on: clinical (HbA1c, BMI, blood lipids, blood pressure) and selected dietary behaviors (starchy foods and energy intake, vegetables and fruit intake) and behavior mediators (knowledge and diabetes management self-efficacy) in patients with type 2 diabetes mellitus (T2DM). METHODS: A tertiary hospital outpatient adults (40-70 years) with poorly controlled (HbA1c ≥ 8 %) T2DM were randomized to either intervention group (n = 39: NEP, 7-monthly group education sessions, bi-monthly follow-up sessions, 15-minute individual session, workbook + education materials) or control group (n = 38: education materials only). NEP aimed to improve clinical status through improved dietary behaviors and behavior mediators. Outcomes and changes in diabetes medication were assessed at six and 12 months. Intention-to-treat analysis was conducted. ANCOVA compared the groups (baseline values, age, sex adjustments). RESULTS: Forty-eight (62.3 %) participants completed the study. Intervention group compared to the control group had lower (-0.53 %), clinically meaningful HbA1c (primary outcome) at 6 months, albeit not sustained at 12 months. Compared to the control group, the intervention group had significantly lower: (i) systolic blood pressure at six and 12 months (ii) diastolic pressure at 12 months, (iii) energy intake at six-months, (iv) up-titration of insulin at six and 12 months and higher diabetes knowledge scores at six months. CONCLUSIONS: NEP had limited effects on HbA1c, targeted dietary behaviors and behavior mediators but showed positive effects on blood pressure. The NEP health cost savings potential supports the need for improving program participation. TRIAL REGISTRATION: ClinicalTrials.gov. number NCT03334773; 7 November 2017 retrospectively registered.

Attitudes and beliefs of South African primary healthcare practitioners on initiating insulin in people with type 2 diabetes: Findings from the Tshwane Insulin Project (TIP).

AIMS: To investigate the attitudes and beliefs of primary healthcare practitioners (HCPs) towards initiating insulin therapy for people with type 2 diabetes (T2D) in South Africa. METHODS: A cross-sectional survey was conducted amongst HCPs from 23 clinics. The nurses' questionnaire was administered by research nurses while doctors completed an online version about their attitudes, beliefs and perceived barriers to initiating insulin. RESULTS: Of the 73 HCPs surveyed, 68% were nurses and 84% were women. Only 24% of HCPs believed that most patients would eventually need to initiate insulin regardless of their adherence to treatment regimens and 86% preferred to delay insulin therapy. Doctors were reluctant to initiate insulin, citing patient-related reasons such as low socio-economic level (41%), inability to refrigerate insulin (77%) and inability to self-monitor blood glucose (55%). Doctors mentioned that patient behaviour including not adhering to treatment regimen and appointments (91%) and reluctance to start insulin therapy (82%) influenced their prescription practices. Doctors mentioned that health system factors, including the pressure to see patients quickly (68%) and lack of continuity of care (64%) were barriers to initiating insulin. CONCLUSIONS: Optimising insulin therapy in primary care requires health system changes including promoting person-centred care and continuing training for HCPs.

Effect of a nutrition education programme on clinical status and dietary behaviours of adults with type 2 diabetes in a resource-limited setting in South Africa: a randomised controlled trial.

OBJECTIVE: To evaluate the effect of a participant-customised nutrition education programme on glycated Hb (HbA(1c)), blood lipids, blood pressure, BMI and dietary behaviours in patients with type 2 diabetes mellitus. DESIGN: A randomised controlled trial. The control group (n 41) received education materials. The intervention group (n 41) received the same education materials and participated in eight weekly (2-2·5 h) group nutrition education sessions and follow-up sessions. Outcomes were assessed at 6 and 12 months. An intention-to-treat analysis was conducted. ANCOVA compared the groups (adjustments for baseline values, age, sex and clinic). SETTING: Two community health centres, Moretele sub-district (North West Province), South Africa. SUBJECTS: Adults (aged 40-70 years) with type 2 diabetes, HbA(1c) ≥8 %. RESULTS: Differences in HbA(1c) (primary outcome) were -0·64 % (P=0·15) at 6 months and -0·63 % (P=0·16) at 12 months in favour of the intervention group. Starchy-food intake was significantly lower in the intervention group, 9·3 v. 10·8 servings/d (P=0·005) at 6 months and 9·9 v. 11·9 servings/d (P=0·017) at 12 months. Median energy intake was significantly lower in the intervention group at 12 months (5988 v. 6946 kJ/d, P=0·017). No significant group differences in BMI, lipid profile, blood pressure and intakes of macronutrients, vegetables and fruits were observed. CONCLUSIONS: Nutrition education was not efficacious on HbA(1c); however, it improved specific dietary behaviours. Group education and hands-on activities appeared to contribute to the improvement. Optimal goal setting and self-efficacy training/assessment could benefit future nutrition education programmes for people with type 2 diabetes mellitus in resource-limited settings.

Needs and Preferences for Nutrition Education of Type 2 Diabetic Adults in a Resource-Limited Setting in South Africa

Diabetes self-management education is crucial in diabetes care. Education that is tailored to the needs of the patient is considered the most effective in improving health outcomes. Diet; a critical element of diabetes treatment; is reported as the most difficult to adhere to by both patients and health professionals. Tailored nutrition education (NE) could benefit diabetic individuals with low socio-economic status; who are amongst those noted to have poor health outcomes. This qualitative interpretive phenomenological study aimed to explore and describe the NE needs of adults with type 2 diabetes mellitus to guide development of a tailored NE programme for resource-poor settings. Participants were 31 non-insulin-dependent type 2 diabetic patients (convenience sample) and 10 health professionals. Focus group discussions using semi-structured questions were held with the diabetics; and open-ended self-administered questionnaires were used with the health professionals. Data analysis was done using Krueger's framework approach. Disease-related knowledge deficits and inappropriate self-reported dietary practices; including intake of unbalanced meals; problems with food portion control and unsatisfactory intake of fruits and vegetables; were observed. Recommendations for the NE programme included topics related to the disease and others related to diet. Group education at the clinic; a competent educator and comprehensive education were indicated by the patients. Participation of family and provision of pamphlets were aspects recommended by patients and health professionals. Barriers that could impact the NE included financial constraints; food insecurity; conflict in family meal arrangements and access to appropriate foods. Support from family and health professionals and empowerment through education were identified as facilitators to following dietary recommendations by both groups of participants. Knowledge deficits; inappropriate dietary practices and barriers are issues that need addressing in an NE programme; whilst the suggestions for an NE programme and facilitators to dietary compliance need to be incorporated