A Tongan Health Society project jointly supported by the Commission with PHARMAC Te Pātaka Whaioranga to understand why Tongan diabetes patients were reluctant to begin insulin treatment has not only resulted in improved medication uptake, but many are now being treated for other, previously undiagnosed conditions as well, thanks to greater engagement with their general practice.
Storyboard summarising the project's aims, approach and outcomes
Tongan Health Society, which serves more than 6,000 patients across three Auckland clinics, wanted to understand why a number of its patients with diabetes who were on the maximum oral diabetic medication were reluctant to step up to the insulin they needed.
The resulting ‘Pacific living with diabetes service’ was one of nine projects from primary care provider teams from around the country selected for the Health Quality & Safety Commission’s 2019 Whakakotahi quality improvement programme.
Primary care teams were supported by the Commission to implement quality improvement projects in an area of patient care they wanted to improve that was important to their patients and community, and to them as providers.
All the projects supported the Commission’s three primary care strategic priority areas of equity, integration and consumer engagement. Equity was given greater importance in the Whakakotahi 2019 selection criteria.
A member of each project team was also offered a position on the primary care quality improvement facilitator course delivered by Ko Awatea and the Commission's primary care and leadership and capability building programmes.
Tongan Health Society was one of three 2019 projects to benefit from the Commission’s partnership with PHARMAC Te Pātaka Whaioranga to support projects with a medicines access equity focus. These projects received additional support from PHARMAC’s manager access equity.
Tongan Health Society clinical services manager, Mele Vaka, says there is little information about Pacific community barriers to starting insulin.
‘For Tongan people, life is about their family, friends and church rather than them as individuals. We knew we needed to engage with these patients and learn more about their individual stories.’
Ms Vaka says using a kakala model – a framework for understanding and connecting with Pacific clients – in conjunction with quality improvement methods – was an important aspect of the project’s approach.
Kakala is a garland of flowers, fruit and leaves worn on special occasions or presented as a sign of love and respect. The three phases of garland-making are used as metaphors and guidance for the research.
The first phase is selecting and picking the most appropriate flora, which is associated with recruitment and data collection. Kau tui kakala is weaving and putting the garland together, which represents the skill, knowledge and insight necessary for data input, analysis and reporting. Finally, luva e kakala is the presentation or gifting of the garland.
‘This is an important part of returning the research to the participants or community so that it can be useful,’ says Ms Vaka.
She says poor understanding about the need for insulin was the biggest barrier for the patient group.
In addition to surveys and questionnaires, the 43 targeted patients who needed to start insulin were invited to workshops on diabetes self-management.
Other Tongan patients already on insulin shared their experiences and those who had recently begun dialysis talked about the impact this had had on their lives. A Tongan renal specialist also spoke at the workshops.
‘This information is better coming from people in the Tongan community who are already on that path,’ says Ms Vaka. ‘Tonga is a very hierarchical society, so we made sure we also involved community and church leaders.
‘Of course, once someone needs dialysis it’s very difficult for them to work and it was important for these patients to understand the impact this would have on them and their families and to try to avoid it.’
She says a fear of needles was an issue for some in the group. ‘While this is not an uncommon fear, some of the patients felt they would actually kill themselves by using an insulin needle.
‘Some had previous bad experiences with very long needles for injections in Tonga and didn’t know the needle used for insulin is very small.
‘Of course, the fear of needles applied to other injections, such as vaccinations, for them and their families as well, so it was important to address it and find ways to make them feel more comfortable.’
Recall nurses played an important part in the success of the workshops, following up those who had said they would come to remind them.
‘We talked to people on the spot when they came in for a check-up with the diabetes nurses who managed their own patient lists.
‘We also got out of the clinic and went to see the hard-to-reach people in their homes or somewhere else that suited them. If you’re a truck driver working seven days a week, from 4am to 7pm, it’s difficult to come into the clinic, so we would meet them during their break.
‘Our diabetes nurse specialist is also a nurse prescriber, so we were able to offer a one-stop-shop that included foot care, diabetic review blood tests and the prescription.’
Insulin therapy patients were provided with free prescriptions, instead of paying a $10 repeat prescription fee, and the onsite Vaiola Pharmacy provided the insulin and other diabetes medication at no cost.
‘This gave us a good indication of whether the targeted patients were regularly refilling their medication,’ says Ms Vaka.
Tongan Health Society chief executive and medical director, Dr Glenn Doherty, says he had been particularly concerned with the impact of macro and microvascular complications on the patients’ wellbeing.
He says 39 percent of the targeted patients have now begun their insulin therapy, the majority of as a result of the Whakakotahi project.
The project team has noticed other improvements, with patients asking about picking up their prescriptions.
There has also been a noticeable increase in the targeted patients engaging with the clinic’s health professionals, with a number now receiving treatment for other previously undiagnosed conditions.