Insulin plus: The impact of modern tools in the management of diabetes in humanitarian settings - a mixed methods assessment of patient and provider experiences

The global burden of diabetes is increasing, with the fastest increase in low- and middle-income settings (1). Type 1 diabetes requires daily injection of insulin for survival, and it is estimated that over 510 million (15%) of people with Type 2 diabetes globally will require insulin for good glycaemic control by 2030 (2). Insulin treatment is challenging in high resource settings. Additional challenges are faced in low-resource or humanitarian settings due to limited availability, accessibility and affordability of both insulin and the associated delivery devices.  The logistical difficulties in monitoring blood glucose and in delivering insulin are often compounded by the environment challenges experienced by providers and patients managing diabetes in settings with limited electricity, light, water and sanitation.  

In recent years, Médecins sans Frontières (MSF), and other humanitarian medical nongovernmental organisations (NGOs), have become increasingly involved in the delivery of care for Type 1 and 2 diabetes in emergency settings. In these, mainly low-and middle-income country (LMIC) settings, older and cheaper approaches to insulin delivery and blood glucose monitoring tend to be used. Three aspects of implementation usually vary in resource-constrained versus high-income settings:

1) Formulation of insulin (human versus analogue);  

2) Delivery device used to inject insulin [needle and syringe versus insulin pen (disposable or reusable with cartridge)]; and  

3) Monitoring device used to assess blood glucose levels and adjust insulin dosing (invasive intermittent versus sensor-based continuous). 

Insulin delivery is challenging in any setting, and these challenges are compounded by the specific difficulties encountered in humanitarian settings, mentioned above. To address these challenges, humanitarian actors, such as MSF, have implemented several of the more modern approaches to insulin delivery, including use of analogue insulin, pen delivery devices and non-invasive glucose monitoring. These approaches are not currently supported by WHO guidance, because the limited available quantitative evidence is equivocal in terms of their added benefits over traditional insulin delivery and monitoring approaches. However, there is lack of published evidence on experiences of managing diabetes with newer insulin-related tools and therapies, in low-and-middle-income country humanitarian settings to help guide decision-making.  Gathering such evidence may serve to improve the current care provided in the relevant MSF programmes and documenting lessons learned may inform scale up of these approaches in other settings and may potentially inform future iterations of the WHO EML and WHO NCD guidance. 

MSF Operations Centre Geneva (MSF OCG) has been providing a spectrum of primary and secondary healthcare in the Dagahaley camp since 2009. In contributing to this overall aim, MSF OCG manages noncommunicable diseases, including diabetes, through primary and secondary health care structures.

Study Aim 

The overall study aim is to document user and health worker experiences of the introduction of specific insulin-related tools: analogue insulin, insulin pens and non-invasive monitoring devices, in Dagahaley camp in Kenya and to identify any challenges in the use of these tools. 

The study research question is: Do newer diabetes tools improve the clinical and self-management of people with diabetes requiring insulin in Dagahaley refugee camp, Kenya? 

Specific Objectives 

1. Document the process and outcomes of implementing modern diabetes tools in a cohort of PLWD-I in Dagahaley camp, Kenya. 
2. Describe the clinical status, diabetes control (HbA1c, time-in-range) Hand occurrence of complications (hypo and hyperglycaemias) of the Dagahaley camp’s diabetes cohort prior to and after the implementation of analogue insulin, insulin pens and CGM.  
3. Describe the experience of using the specific insulin delivery/monitoring approach from the patient perspective, in terms of treatment satisfaction and health-related quality of life. 

Secondary objectives 

1. Describe the socio-demographic and diabetes-related characteristics of PLWD-I accessing analogue insulin, insulin pens and CGM in the Dagahaley camp. 
2. Describe the experience of using the specific insulin delivery/monitoring approach from the provider perspective, in terms of ease of use, acceptability and normalisation into usual workflow.    
3. Detail the process undertaken to prepare and educate PLWD-I and clinicians for the use of analogue insulin, insulin pens and CGM in the Dagahaley camp. 

1-Whiting DR, Guariguata L, Weil C, Shaw J. IDF diabetes atlas: global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract. 2011;94(3):311-321. doi:10.1016/j.diabres.2011.10.029 

2- Basu S, Yudkin JS, Kehlenbrink S, et al. Estimation of global insulin use for type 2 diabetes, 2018-30: a microsimulation analysis. lancet Diabetes Endocrinol. 2019;7(1):25-33. doi:10.1016/S2213-8587(18)30303-6