Supplying solutions: A mixed-methods study on experiences with access to diabetes care supplies in four African countries to inform the development of a bundled solution for improved self-care and clinical management

Supplying solutions: A mixed-methods study on experiences with access to diabetes care supplies in four African countries to inform the development of a bundled solution for improved self-care and clinical management | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Supplying solutions: A mixed-methods study on experiences with access to diabetes care supplies in four African countries to inform the development of a bundled solution for improved self-care and clinical management Siri Wood, Laura Meyer, Lindsay Rubin, Gerald Robi, Geraldo Sitoe, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7707279/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Consistent access to high-quality medicines and affordable health products remains a persistent challenge for people living with diabetes (PLWD) in low- and middle-income countries. PLWD lack access to essential commodities to prevent diabetes-related complications, face catastrophic out-of-pocket costs, are often unable to monitor their blood sugar, may ration medication and reuse syringes, and have limited access to diabetes education. This publication presents findings from a mixed-methods landscape assessment and retail outlet survey conducted between 2022 and 2024 in Mali, Mozambique, Tanzania, and Uganda to understand diabetes self-care and management practices, barriers to and facilitators of care, retail costs, and access to medicines and supplies. The results of the study informed a human-centered design process to develop a prototype diabetes self-care kit called the “Diabetes CarePak.” Methods: The study team conducted semi-structured in-depth interviews and focus groups with PLWD, health care workers, and stakeholders in Mali, Mozambique, Tanzania, and Uganda to assess key issues related to diabetes self-care and disease management. The study included a retail outlet survey of 150 public and private outlets across the four countries to examine the pricing and stock levels of essential supplies. Subsequently, human-centered design approaches were used in cocreation workshops with end users in each country to develop a prototype kit of diabetes management supplies and educational and health care worker training materials. Results: Study findings underscore significant barriers to access to and affordability of essential diabetes care supplies, including the unavailability of blood glucose testing even at local health clinics, low ownership of glucometers, difficulty finding brand-matched test strips, and inconsistent stock and high costs of diabetes supplies in pharmacies and retail outlets. Financial hardship and food insecurity impeded individuals’ ability to monitor glucose, adhere to medication, seek care at health facilities, and follow nutritional guidance. Conclusions: This study documented key diabetes self-care challenges, highlighted the advantages and desirability of a bundled solution, and employed a human-centered design to develop the CarePak prototype. diabetes self-care supplies access affordability Diabetes CarePak human-centered design Figures Figure 1 Figure 2 Background Recent evidence suggests that 1.3 billion people will have diabetes by 2050, with 80% living in low- and middle-income countries (LMICs). 1,2,3 To meet the World Health Organization’s target of 100% of people living with diabetes (PLWD) having access to affordable insulin and blood glucose self-monitoring by 2030, it is crucial to identify and address individual, social, and health system factors that challenge effective disease management. 4,5,6 Many PLWD in LMICs face barriers such as stockouts and high out-of-pocket costs, which prevent them from acquiring the medicines and products needed to measure blood glucose (glucometers, test strips, lancets) or safely administer insulin (needles and syringes). This inconsistent access to insulin and supplies leads to serious consequences when PLWD are unable to monitor their blood sugar levels, must ration medication or test strips, or reuse insulin syringes. 7,8 Rationing leads to increased pain due to the dulling of needles and increases the risk of infection, hyperglycemia or hypoglycemia, and long-term complications such as amputation, blindness, kidney failure, and death. Associated morbidity also causes substantial economic losses to PLWD, their families, health systems, and national economies through direct medical costs and loss of wages. 9,10 This unmet need is a call for innovation in service delivery and improved access to self-care supplies to support better clinical management. This publication outlines the findings of a landscape assessment and retail outlet survey conducted between 2022 and 2024 in collaboration with ministries of health in four countries—Mali, Mozambique, Tanzania, and Uganda—to understand diabetes self-care and management practices, barriers to and facilitators of care, retail costs, and access to medicines and supplies. These countries were selected based on donor and government interest in advancing diabetes supply initiatives. The study identified key obstacles and enablers related to accessing diabetes self-care supplies and informed the development of a prototype kit for diabetes management supplies in each country. The landscape and retail outlet survey findings underscore the critical issues of the accessibility and affordability of supplies, highlight the significant need for education on nutrition and disease management, and outline the essential commodities that could be bundled to improve self-care. Following the landscape and retail outlet survey, PATH brought together PLWD and other stakeholders in human-centered codesign workshops to develop Diabetes CarePak, a bundled solution designed to increase access and affordability, facilitate self-care and clinical management of blood glucose, and improve quality of life. Methods Study aims PATH conducted a mixed-methods study in Mali, Mozambique, Tanzania, and Uganda between November 2022 and January 2024 to understand the health care journey of PLWD, identify the costs and barriers to accessing supplies necessary for safe insulin administration and diabetes self-management, and inform the development of Diabetes CarePak. More broadly, the CarePak project aims to demonstrate the benefits and cost-effectiveness of CarePak to the health system, advocate for national health coverage to support broader uptake, and improve access to safe insulin administration by increasing the availability of supplies. User testing, health impact data, and cost-effectiveness analysis are reported in separate publications. Design The study comprised three parts: semi-structured, in-depth individual interviews with PLWD, health care workers (HCWs), and stakeholders; a quantitative survey of retail outlets and pharmacies; and human-centered design workshops to develop CarePak. The study adhered to the ethical principles of the Declaration of Helsinki, including administration and obtention of informed consent for all participants. Several complementary focus group discussions (FGDs) were conducted with PLWD in Mozambique, Tanzania, and Uganda. No FGDs were conducted in Mali due to time and resource constraints. The retail outlet survey included private and government-owned pharmacies across the participating districts. It documented the availability and prices of commonly used supplies for insulin administration and blood glucose monitoring, including syringes, glucometers, test strips, and alcohol swabs. Findings from the landscape survey informed the development of a Diabetes CarePak prototype through codesign workshops, as well as educational materials for PLWD and training materials for HCWs. The Diabetes CarePak is a bundled solution developed to improve access to supplies necessary for safe insulin administration and self-care, enhancing quality of life and diabetes-related health outcomes. Site selection By working with the ministry of health (MOH) in each country, study sites were selected to optimize geographic representation, including rural and urban areas, prioritizing facilities with high patient volume, functional patient databases, and a mix of public, private, and faith-based facilities (Table 1). Table 1. Distribution of study sites by region and country Bamako Commune IV Province/region and district # of facilities Mali Mozambique Tanzania Uganda Bamako Commune IV 1 Bamako Commune VI 1 Koulikoro 1 Sikasso 1 Maputo Province (Maputo City) 3 Nampula Province (Nampula City) 1 Kilimanjaro (Same District) 3 Dar es Salaam (Ubongo Municipal Council) 3 Kigoma (Kigoma District Council) 3 Mwanza (Nyamagana Municipal Council) 3 Eastern Region (Namutumba District) 2 Eastern Region (Jinja District) 2 Eastern Region (Mbale District) 2 Total 4 4 12 6 Participants and sampling strategy Purposive sampling was used to recruit individuals aged 18 to 70 years with a diagnosis of type 1 or type 2 diabetes mellitus (T1D or T2D) who had been taking insulin or other treatment for more than six months, as well as HCWs with primary responsibility for providing diabetes-related care at the participating facilities. No formal power calculation was conducted, as the study focused on describing experiences and access to supplies. For interviews with PLWD, data saturation was reached after 15-20 interviews, as interview transcripts beyond that point revealed no new codes or themes related to participant experiences. A large sample was retained so as to account for differences in experiences of participants between gender, age, and across urban and rural sites (Table 3). Participants were recruited from medical records or outpatient clinic waiting rooms. Informed consent was obtained from all participants. Stakeholders who participated in the codesign workshops included PLWD, HCWs, MOH representatives, and staff from local patient support associations, all of which were purposively selected to ensure diverse perspectives. A survey of medical retail outlets in the participating districts was conducted to assess the availability and cost of common diabetes management supplies. The outlets included private pharmacies and government-owned pharmacies co-located at health facilities, with numbers varying by setting on the basis of available time and resources (Table 2). The types of outlets reflect the categories used in each country during data collection. Table 2. Number and type of retail outlets surveyed by country Country Outlet type Number Mali (n=32) Private 28 Public 4 Mozambique (n=36) Private 35 Public 1 Tanzania (n=70) ADDO 1 25 Health facility 15 Pharmacy 30 Uganda (n=12) Health facility 2 Pharmacy 10 Note: The number of outlets surveyed reflects the time and resource constraints in each setting. The outlet types shown are based on the categories used during data collection in each country. Data collection and analysis Semi-structured qualitative guides were used to interview PLWD, HCWs, and other stakeholders, and a list of possible supplies was used to identify participants’ preferences for items to be included in CarePak. The interviews were conducted in local languages (Bambara in Mali, Portuguese in Mozambique, Swahili in Tanzania, and Lugisu or Lusoga in Uganda), audio-recorded, transcribed, and translated into English. FGDs and in-depth interviews (IDIs) were conducted at health facilities or other spaces that provided auditory privacy. Data collection took place between October 2022 and April 2023, except in Mali, where it occurred in January 2024. An initial coding framework was developed, and the interview transcripts were coded via NVivo v14 software. 11 A thematic approach was applied to analyze the transcripts, explore patterns in the data, and contextualize findings with literature. We used a combined inductive and deductive approach to code development, beginning with a set of codes derived from theory. During analysis, we looked for new codes that emerged from insights in the data to refine, expand, or modify the initial framework. To ensure consistency, coding was led by one individual with oversight by, and discussion with, other team members at periodic check ins during the analysis process.In each country, PATH staff trained in human-centered design (HCD) facilitated interactive workshops to cocreate prototype CarePak kits with PLWD and HCWs. During the workshops, the participants engaged in creative exercises, including brainstorming and card-sort ranking, and were provided with a range of materials (paper, cardboard, tape, objects of various shapes and sizes) to create low-fidelity physical prototypes of their desired CarePak. Participant feedback guided item selection and organization in kits, reflecting items that participants identified as necessary and most useful. Health care supplies were then procured to assemble a high-fidelity prototype CarePak for validation with MOH representatives. Data from the retail outlet survey were tabulated and reviewed in Excel to describe the availability, costs, and colocation of diabetes-related products at retail sites. Ethics approval The study was approved by the Western Institutional Review Board (WIRB)-Copernicus Group Institutional Review Board (WCG IRB) in the United States (June 8, 2022); the Mildmay Uganda Research Ethics Committee (MUREC) (August 29, 2022); the Uganda National Council for Science and Technology (UNCST) (October 11, 2022); the Tanzania National Institute for Medical Research (NIMR) (September 2, 2022); the Mozambique Comité National da Bioética para a Saúde (CNBS) (December 15, 2022); and the Comité National d’Éthique pour la Santé et les Sciences de la Vie (CNESS) in Mali (May 8, 2023). Results Participants A total of 498 individuals participated in the study. Table 3 shows the number of IDIs and FGDs conducted in each country. Table 3 Number of participants by category and by country Mali Mozambique Tanzania Uganda Total Individual interviews PLWD 137 72 25 43 277 HCWs 8 8 21 6 43 Stakeholders 6 2 10 0* 18 Pharmacy staff 25 40 7 6 78 Focus group discussions PLWD 0 22 (3 FGDs) 14 (2 FGDs) 46 (2 FGDs) 82 (7 FGDs) *The number of participants interviewed varied by country based on available budget, time, and human resources in each setting. Among the 277 PLWD interview participants, 60% were female, and 40% were male. The average age of the PLWD participants was 55 years. In Mozambique, Tanzania, and Uganda, 18% had T1D, 74% had T2D, and 8% did not know their type. In Mali, 99% of the patients had T1D. The results are organized around the three components of the study: qualitative interviews and focus group discussions, the retail outlet survey, and the cocreation workshops. Together, these findings provide a holistic view of the barriers faced by PLWD and directly inform the design of the CarePak integrated care package. Qualitative IDIs and FGDs with PLWD The study team conducted IDIs and FGDs to explore the health care journeys and personal experiences of PLWD. The topics explored included participants’ reactions to their diagnosis, social support, self-management practices such as medication adherence and blood glucose testing, accessibility and affordability of diabetes medication and supplies, knowledge about diabetes and disease management, and diet and nutrition. Diagnosis experiences and social support A common complicating factor during the initial diabetes diagnosis for many PLWD is symptom overlap with other infectious diseases, such as malaria, tuberculosis, and HIV. Two-thirds of the participants reported having other health conditions associated with diabetes, most commonly hypertension (more than half), cardiovascular disease, and nonhealing ulcers or wounds (a significant minority). A minority of participants reported being HIV positive. Nearly half of the participants across all countries experienced negative reactions to their diabetes diagnosis, including anxiety, fear, or worry. Approximately one in four participants reported having a mixed or neutral reaction, whereas a minority said they were happy to finally have a confirmed diagnosis. Negative reactions were more likely among individuals who lacked social support, faced financial hardship, lost a loved one to diabetes complications, or were living with a comorbidity. Those who had received counseling or health education from a health provider reported responding more positively to their diagnosis. Many participants reported that emotional support from other PLWD, health care providers, and their loved ones strengthened their motivation for self-care. Over half of the participants reported that a family member accompanied them to a health facility when they felt unwell. Participants in Mozambique reported more social support resources than those in other countries did, citing involvement with the Mozambican Diabetes Association (AMODIA) support group program. A minority of Tanzanian participants also reported being part of a support group. Diabetes self-management The study participants identified the three most challenging aspects of self-management as follows: 1) taking medicines as directed, 2) monitoring blood glucose levels, and 3) following dietary guidelines, primarily because of the high cost and limited availability of diabetes medication and care supplies, as well as food insecurity. The participants reported that the high cost of glucometers and limited access to affordable test strips and lancets were the major barriers to testing their blood glucose regularly at home. Approximately one-third of the participants across all four countries said that they owned a glucometer but could no longer use it because matching test strips were unavailable or out of stock at public and private pharmacies. Nearly all the participants said that they wanted reliable access to glucometers and supplies to test their blood glucose at home and improve monitoring. “I go to the hospital for blood sugar tests; I don’t have a testing machine. I test every two days, and I pay for it. I don’t have health insurance, and the cost of injections is too high.” – Male PLWD in Tanzania, age 46 “Going to the health center to measure my blood glucose is tiring, and I need my children to help me administer my medication.” – Female PLWD in Mali, age 55 Accessibility and affordability of medication and supplies Across all countries, financial hardship and the high cost of medication were significant barriers to diabetes management for nearly all participants, limiting their ability to consistently buy and take insulin and oral medications as directed. Participants across all study countries reported needing help from a relative to pay for medication, either periodically or regularly. This was often due to disability, unemployment, or underemployment. The participants reported frequent stockouts of injectable and oral medications at hospital- and clinic-based pharmacies, whereas private pharmacies had fewer stockouts but charged more, making them less affordable. Consistent with these qualitative reports from PLWD, significant stockouts of supplies were documented in the retail outlet survey reported below. PLWD using insulin stated that they were prescribed an average of 15 syringes per month and typically reused each syringe at least twice. Many participants reported reusing a single syringe for several days or up to a week before discarding it. The participants said that procuring supplies often required visiting multiple locations, creating a financial burden due to transport costs and lost income from time away from work. Many participants reported that having diabetes added a financial burden on their family or household due to the ongoing costs of treatment and lifestyle changes. “It has happened before when I was unable to buy medicine for a week. I got sick, and my blood sugar went up a lot. I was hospitalized when I couldn’t afford it. There is no one to help me but myself because my mother is sick, and she had a stroke.” – Female PLWD in Tanzania, age 39 “My son helps me. When I don’t have money while I have a prescription—for example, today I have to buy medication and I haven’t received it yet—when he has money, he’ll give it to me to buy.” – Female PLWD in Mozambique, age 65 Cost of transportation and distance to medical treatment or pharmacy Most participants said that transportation costs were another financial burden. Factors contributing to transportation costs included frequent appointments, distance to hospitals or clinics, and whether medications and supplies could be obtained at the hospital or local pharmacy. Half of the participants traveled for at least 45 minutes to reach the clinic, often using public transportation, which added to their costs. Participants who traveled farther to a clinic or a pharmacy cited time and transport costs as barriers to medication adherence. Several participants reported walking to their appointments due to a lack of money for transportation. “Sometimes, to come to the hospital, I have to save money for three weeks so I can have money for a minibus. If I don’t do that, that day will come, and I won’t be able to go to the appointment because I don’t have the money.” – Female PLWD in Mozambique, age 62 “It’s two hours to go and return. It disturbs me, yes, because if medication were available, the time I am using to search for medicines, there are customers waiting for me.” – Female PLWD in Tanzania, age 24 Knowledge and education about diabetes PLWD identified several areas of diabetes management that they wanted to learn more about, especially diet and nutrition. Most participants reported receiving basic dietary advice at diagnosis but wanted more detailed information on diabetes-friendly diets, including how to balance their diets with a limited budget and adjust their eating habits based on fluctuating blood glucose levels. PLWD also wanted to learn how to prevent diabetes, teach family members about it, and understand the difference between T1D and T2D. “I would like to get more education about the proper diet for diabetic patients, the right time to eat, and how to plan foods, because there are many misconceptions that confuse diabetic patients.” Male PLWD in Tanzania, age 21 “Alternative ways of using certain products—for example, if I don’t have sorghum, what can I use as an alternative? If I don’t have olive oil, what can I use as an alternative because oil is no longer available?” ––PLWD in Mozambique, age 39, gender not recorded Dietary practices Across all four countries, nearly all participants reported that they had made changes in their diets and eating habits since being diagnosed with diabetes, such as cutting back on oil, fatty meats, sugary drinks, starches, or dairy. Common dietary challenges reported by participants included eating separately from other family members or depending on others to cook for them (in-laws, spouses, etc.). Most said that diet changes were financially burdensome, as they could not afford the recommended foods to replace high-glycemic foods (e.g., olive oil). Some individuals reported eating very little or skipping meals when they lacked access to low-glycemic foods. HCWs confirmed that financial challenges affect PLWD’s dietary choices. “Here, many people die from this disease because of the lack of conditions; food is also part of the aggravation of the disease itself. If they tell you that you can’t eat this and you don’t have anything else at home, you have to eat to relieve your hunger.” – Male PLWD in Mozambique, age 56 “I don’t go to parties anymore..., as there are only things I don’t eat. It’s not normal to go to a party and have to take your lunchbox with you. For other people, it’s already a nuisance—you just come to talk, and you don’t eat, and you don’t do anything else—so it’s better not to go.” – Female PLWD in Mozambique, age 49 Retail outlet survey Building on the barriers identified in the interviews and focus groups, the retail survey assessed the availability and retail prices of essential diabetes supplies to evaluate access to and affordability in local markets. The retail survey identified frequent stockouts of supplies, price variability within and across countries, and low rates of colocation of insulin with other diabetes supplies. The survey thus quantified and reinforced key qualitative themes—particularly those concerning inconsistent supply, affordability barriers, and the burden of traveling to multiple outlets. Stockouts and availability The survey revealed regular stockouts of essential diabetes supplies in all four countries, especially glucometers, test strips, and sharps containers. Alcohol bottles were consistently available, reflecting their utility in general health care, whereas alcohol swabs showed striking shortages—especially in Mali (100%) and Tanzania (95%)—likely due to alternative disinfection methods (Fig. 1 ). Note n = may not equal the total number of outlets surveyed because not all outlets had sufficient data collected to calculate stock and availability. ADDOs in Tanzania were included but inherently may not generally offer as many supplies as larger outlets do. Stockout rates for blood lancets ranged from 33% in Uganda to 80% in Tanzania. Mozambique (42%) and Mali (48%) showed moderate unavailability. Glucometers had high unavailability rates across all countries, with Tanzania (57%) experiencing the highest stockout, followed by Uganda (42%), Mozambique (33%), and Mali (29%). Test strips showed similar levels of unavailability, ranging from 32% in Mali to 42% in Uganda. Insulin syringe stockouts varied, with Mali (3%) reporting the lowest stockout rate and Uganda (42%) and Tanzania (26%) experiencing the highest shortages. Insulin vials were entirely unavailable in Mali (100%), underscoring systemic barriers to stocking insulin alongside other essential diabetes supplies. Other countries faced similar challenges, with unavailability ranging from 42% in Uganda to 67% in Mozambique. Insulin pens were generally less available, aligning with global trends, except in Mali, where only pens were stocked, highlighting a unique deviation. The patterns of stockouts revealed by the survey provide important context for understanding the affordability and access issues reported by PLWD, which are further explored in the pricing analysis below. Pricing The survey documented the retail prices for the average number of unbundled supplies required monthly for safe insulin injection and blood glucose testing (Table 4 ). The product quantities represent a month’s worth of standard diabetes care supplies, similar to the “Diabetes CarePak Insulin Starter Kit.” The CarePak kit includes 100 grams of cotton wool and either a 100 mL bottle of alcohol or 50 alcohol swabs for hygiene and injection site preparation. For blood glucose monitoring, the kit contains a glucometer, 50 test strips, and 50 lancets for consistent and accurate glucose self-monitoring. It also includes 30 insulin syringes to support daily insulin administration, although this may not fully meet all needs for PLWD. Although insulin vials and pens are excluded from the bundle, the quantities are standardized to represent a month’s supply for a PLWD: one 10 mL vial of insulin and one insulin pen. This standardized approach allows for comparisons across countries. Table 4 Average retail purchase price for unbundled supplies required monthly for safe insulin administration Mali Mozambique Tanzania Uganda All countries Included in CarePak N Average N Average N Average n Average n Average Alcohol bottle 41 $ 1.63 31 $1.05 76 $ 0.43 9 $0.57 157 $0.88 Alcohol swabs* 0 - 16 $ 1.85 3 $ 3.58 7 $ 0.81 26 $ 1.77 Blood lancet 17 $ 8.77 23 $ 8.79 9 $ 3.59 8 $ 9.12 57 $ 8.01 Cotton wool 65 $ 2.41 31 $1.66 155 $ 0.96 10 $0.89 261 $1.40 Glucometer 41 $ 33.16 24 $ 41.36 28 $ 19.50 18 $ 17.42 111 $ 29.59 Glucose test strips 39 $ 27.47 23 $ 21.24 51 $ 7.40 18 $ 13.15 131 $ 16.59 Insulin syringe 36 $ 6.46 29 $ 7.80 31 $ 5.91 8 $ 6.20 104 $ 6.65 Sharps container** 2 $ 4.40 0 - 1 $ 15.05 0 - 4 $ 7.95 Total price of commodities $84.29 $81.03 $55.02 $46.71 $70.56 Excluded from CarePak Insulin 84 $ 8.00 12 $ 20.04 55 $ 7.31 19 $ 7.54 170 $ 8.57 Insulin pen 28 $ 64.86 9 $ 25.39 3 $ 10.75 8 $ 10.88 48 $ 45.08 *Owing to overlap in use cases, the price of alcohol swabs was excluded from the total price of the commodities bundle in Mali. The price of alcohol bottles and cotton wool was excluded from the total price of the commodities bundle in Mozambique, Tanzania, and Uganda. **The price of sharps containers was excluded from Mozambique and Uganda because of a lack of data. The prices of general consumables—cotton wool (100 g), alcohol bottles (100 mL), alcohol swabs (50), and blood lancets (50)—varied widely across countries but showed consistent trends in cost drivers. Tanzania had the lowest prices overall, whereas Mozambique presented the greatest variability and highest outliers. Cotton wool is relatively inexpensive and widely accessible across countries. The number of alcohol bottles used ranged from $ 0.04 to $ 4.61, with Mali reporting the highest average price ( $ 1.63). Instead of purchasing both separately, PLWDs could opt for alcohol swabs, which were slightly more expensive, with Mozambique reporting an average of $ 1.85. Lancet prices varied widely, peaking at $ 61.02 in Uganda, with an average of $ 8.00 across all countries. These price outliers suggest supply chain inefficiencies in some regions. Data for sharps containers were limited, with an average cost of $ 7.95 reported. Limited data suggest alternative—and possibly improper—shared disposal methods across countries. The average cost for insulin syringes (30 syringes) across countries was $ 6.65. Prices varied widely across countries, with Mozambique reporting the highest average cost of $ 7.80. In-country price variability was greatest in Tanzania, with prices ranging from $ 1.29 to $ 25.79. The single-unit price for glucometers ranged widely, with averages from $ 19.50 in Tanzania to $ 41.36 in Mozambique. Mali reported the highest price at $ 102.54. Despite being a one-time investment, the high upfront cost can be a barrier to adoption. Test strips (30 strips) were a recurring expense, averaging from $ 7.40 in Tanzania to $ 27.47 in Mali. Insulin vials and pens were excluded from the bundle price, but colocation with other supplies remains critical for safe and consistent use. Prices for insulin vials (10 mL) were more stable, averaging from $ 7.31 in Tanzania to $ 20.04 in Mozambique. Across all countries, the average price was $ 8.57, highlighting the importance of streamlined procurement to ensure affordability. The cost of insulin pens varied significantly, from an average of $ 10.88 in Uganda to $ 64.86 in Mali. These disparities reflect variations in market dynamics, distribution, and competition. The pricing and availability challenges documented in the retail survey, combined with the access barriers described in the interviews and focus groups, underscore the need for a bundled diabetes care solution. This led to cocreation workshops aimed at developing the CarePak prototype to improve supply access and self-management. These pricing data directly mirror the affordability challenges described by PLWD in interviews—where participants reported rationing medication, reusing syringes, and skipping glucose testing due to unaffordable supplies. For instance, the high costs of glucometers and test strips observed in Mali and Mozambique correspond to participant accounts of discontinued home testing, while lower relative prices in Tanzania may explain slightly greater testing consistency reported there. Kit design and cocreation workshops Between February and April 2023, PATH held cocreation workshops in Mozambique, Tanzania, and Uganda with PLWD (n = 29) and HCWs (n = 11) to envision an essential package of diabetes management supplies through a series of exercises. The supply kit would ideally enable users to track daily blood glucose levels to share with medical providers, supporting better clinical decision-making and care. After discussing availability and other challenges identified in the landscaping interviews, attendees designed a low-fidelity CarePak prototype containing the desired supplies. The participants used cardboard cutouts to visualize different bundle configurations. The final approved products were then purchased and assembled to create a high-fidelity prototype, as shown in Fig. 2 . During these workshops, the study team proposed content for an HCW training curriculum and an education booklet for PLWD, which was based on earlier versions developed by PATH in Kenya and incorporated input from participants interviewed during the landscaping phase. These materials were adapted to each country’s context and aligned with national diabetes management guidelines. PATH then convened stakeholder meetings to validate the kit components. The cocreation workshops and validation meetings resulted in a prototype kit tailored to each country. Four CarePak versions were developed: a starter kit and a monthly refill kit for both insulin and oral medication users. Table 5 presents the contents of the four kit configurations. Table 5 Kit contents and commodity quantities Kit item Insulin kits Oral medication kits Starter kit Refill kit Starter kit Refill kit Glucometer 1 - 1 - Test strips 100 100 50 50 Lancets 100 100 50 50 Alcohol swabs 100 100 50 50 Insulin syringes 30 30 - - Sharps container 1 - 1 - Blood glucose log 1 - 1 - Education booklet 1 - 1 - Storage box or bag 1 1 1 1 Discussion Although some programs address access to insulin and essential supplies in sub-Saharan Africa, little evidence exists on holistic diabetes self-management interventions or on the qualitative factors shaping self-care. As LMIC health care systems invest more in noncommunicable diseases, understanding the individual, social, and system-level influences on diabetes management is essential. 12,13 In this study, IDIs, FGDs and a retail survey highlighted how supply shortages, economic strain, and limited education constrain daily self-management. This assessment also identified essential commodities that could be bundled to improve access. Four standardized kits were co-designed during workshops with PLWD, which PATH tested with users in each country (the results are reported separately). Limited accessibility and affordability of diabetes supplies and medications emerged as the most significant barriers across all countries. Participants’ accounts reflected prior findings that supply unavailability and high costs undermine health and financial security of PLWD and their families. 6,7 Many described being inconsistent access glucometers and testing supplies, with brand-matched test strips and reagents further restricting use. 6, 17,21 Retail data corroborates these experiences, showing frequent stockouts and wide pricing disparities; in areas with the highest prices or lowest availability, participants often relied on clinics for testing or went without monitoring. Financial hardship and food insecurity also limited participants’ ability to monitor blood glucose, take medication consistently, seek care, and follow nutritional guidance – challenges well documented in LMIC settings. 16 ,14,15,16,17, 27 This study extends existing evidence by capturing PLWD and HCWs experiences on bundled supplies and their potential to reduce those barriers. Free diabetes treatments and medications were limited in all four countries, consistent with patterns across LMICs.11 ,18,19,20,21,22,23,24 Participants commonly visited multiple facilities due to stockouts or paidhigher private-sector prices. Even when supplies were available, transportation costs, time away from work, and physical strain created additional burdens. 25,26 Few studies have examined bundling diabetes medications and supplies. The codesigned workshops responded directly to access and affordability challenges, producing a bundled solution that consolidates essential items, reduces costs through bulk purchasing, and eliminates the need to visit multiple outlets. Participants viewed the CarePak as an affordable, convenient option for obtaining consumables. Diabetes self-management is influenced by personal, social, and health system factors and benefits from comprehensive education. 27,28 Participants expressed interest in practical guidance on nutrition and blood glucose control. These needs Informed the development of the CarePak booklet, though further HCW training is needed to support comprehensive nutritional counseling and clinical follow-up. HCD has been widely applied to NCD interventions in countries such as Kenya, a cardiovascular disease program in HIV clinics, and digital health initiatives in LMICs, among other applications. 29,30,31 PATH has a strong history of using HCD to develop sustainable, user-friendly solutions. In this study, design activities drew on lived experiences and retail data to inform kit content, ensuring that the prototype CarePak reflected both user priorities and market realities. The retail outlet survey revealed substantial gaps in the availability and affordability of essential medicines and technologies, falling short of WHO targets. The retail survey’s quantitative findings, when analyzed alongside the qualitative results, underscore a systemic misalignment between supply chain functionality and patient realities: even where supplies exist, they remain financially or geographically out of reach. Stockouts of glucometers, test strips, lancets, and sharps containers, as well as high and variable prices, underscored the misalignment between supply chain performance and patient needs. Inconsistencies in insulin and syringe availability likely reflect procurement inefficiencies, weak regulation, and limited market competition. Centralized procurement, pooled purchasing, and local or regional production may help stabilize pricing. The high recurring cost of test strips remains a major barrier; subsidies or donor-supported distribution could improve access. Conclusion This study adds to the limited literature on diabetes self-management in sub-Saharan Africa and reinforces the substantial financial and logistical burdens faced by PLWD in Mali, Mozambique, Tanzania, and Uganda. 11 , 15 , 12 ,32,33,34,35 Findings underscore the need for interventions at both individual and societal levels – such as expanded HCW training improved price regulation; increased availability of affordable supplies; and strengthened support for self-monitoring and lifestyle management. The study also informed the development of a bundled kit to support safe insulin administration, with strong participant interest in such a solution. Further research should assess the acceptability, usability, and health impacts of the CarePak prototypes and explore complementary approaches, including enhanced diabetes education, peer support, and strategies to address food insecurity and the affordability of healthy foods. The growing diabetes burden in sub-Saharan Africa requires increased attention, resources, and innovation in clinical practice, social support, and technology. Alongside broader health system strengthening, interpersonal and community-level interventions remain essential to support lifelong diabetes self-management. Limitations This study employed purposive sampling, which gave country teams flexibility in selecting eligible participants for interviews; however, the sample may not be representative of the broader population, limiting the generalizability of the results to other settings. The use of interviews in this study, while providing rich insights, is subject to social desirability bias, where participants may have responded in ways they believed were more socially acceptable rather than reflecting their true beliefs or behaviors. Further, data collection relied on a voluntary survey of retail outlet managers, which is susceptible to non-response bias Verbatim quotes were less extensive in Mali and Uganda due to shorter responses and the use of different data capture tools, such as Miro boards, instead of audio recordings. List of abbreviations ADDO accredited drug dispensing outlet FGD focus group discussion HCD human centered design HCW health care worker IDI in-depth interview IRB institutional review board LMIC low- and middle-income country MOH ministry of health PLWD people living with diabetes T1D type 1 diabetes T2D type type 2 diabetes Declarations Ethics approval and consent to participate. The study was approved by the WIRB-Copernicus Group (WCG IRB) in the United States (June 8, 2022, research registration number 1334159); the Uganda National Council for Science and Technology (UNCST) (October 11, 2022, research registration number HS2418ES); the Mildmay Uganda Research Ethics Committee (MUREC) (August 29, 2022, research registration number MUREC-2022-133); the Tanzania National Institute for Medical Research (NIMR) (September 2, 2022, research registration number NIMR/HQ/R.8a/Vol/IX/4100); the Mozambique Comité National da Bioética para a Saúde (CNBS) (December 15, 2022, research registration number 861/CNBS/22); and the Mali Comité National d’Éthique pour la Santé et la Science de la Vie (CNESS) (May 8, 2023, research registration number 2023-091/MSDS-CNESS). Consent for publication. Not applicable (deidentified data only). Availability of data and materials. The question guides used and datasets analyzed during this study are available from the corresponding author upon reasonable request. Competing interests. The authors declare that they have no competing interests. Funding. The study in Mali, Mozambique, and Tanzania was conducted by PATH with support from The Leona M. and Harry B. Helmsley Charitable Trust. The study in Uganda was supported by Sanofi. The funders had no role in the study’s conceptualization, design, data collection, analysis, decision to publish, or manuscript preparation. Authors’ contributions. SW: project administration, supervision, formal qualitative analysis, writing (original draft, review, and editing). LR: writing (original draft), formal qualitative analysis. GA, GR, AM, GS, and BM: investigation. LM: project administration, writing (review and editing). AP: formal analysis (retail outlet survey). HM: funding acquisition, writing (review and editing). All contributing authors reviewed and approved the final version of the article. Acknowledgments. The team extends gratitude to collaborators from each country’s ministry of health, including district health officers and chief administrative officers in Uganda, as well as the President’s Office of Regional and Local Government (PORALG) in Tanzania. In Mozambique, the nonprofit Mozambique Diabetes Association (AMODIA) was instrumental in facilitating interviews with PLWD and HCWs, as were the Tanzania Diabetes Association (TDA) and the Uganda Diabetes Association (UDA). Gratitude is extended to PATH countries and global staff who support implementation, including Amy Heyden, Melanie Picolo, Betty Mirembe, Aminatou Sar, and Kevin Masibo. References The top 10 causes of death. Geneva: World Health Organization; 2020. https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death GBD 2021 Diabetes Collaborators. Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021. Lancet, 2023. https://doi.org/10.1016/S0140-6736(23)01301-6 Flood D, et al. The state of diabetes treatment coverage in 55 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data in 680 102 adults. Lancet Healthy Longevity. 2021 Jun;2(6):e340-e351. doi: 10.1016/s2666-7568(21)00089-1. Stephani V, Opoku D, Beran D. Self-management of diabetes in sub-Saharan africa: A systematic review. BMC Public Health. 2018;18(1). doi:10.1186/s12889-018-6050-0 Song Y., Beltran Puerta J., Medina-Aedo M., et al. Self-Management Interventions for Adults Living with Type II Diabetes to Improve Patient-Important Outcomes: An Evidence Map. Healthcare, 11(24), 3156. 2023. https://doi.org/10.3390/healthcare11243156 World Health Organization. https://www.who.int/news-room/feature-stories/detail/first-ever-global-coverage-targets-for-diabetes-adopted-at-the-75-th-world-health-assembly (Accessed June 27, 2025) Diabetes Supplies: Are they there when needed? Seattle: PATH; 2015. https://media.path.org/documents/NCD_nes_exec_summary_CxMJvC8.pdf Alijanzadeh, M., Hashemipour, S., Attaran, F. et al. Availability and affordability of diabetes healthcare services associated with the frequency of diabetes-related complications. BMC Health Serv Res 24, 1586 (2024). https://doi.org/10.1186/s12913-024-12065-x Seuring T, Archangelidi O, Suhrcke M. The Economic Costs of Type 2 Diabetes: A Global Systematic Review. Pharmacoeconomics. 2015 Aug;33(8):811-31. doi: 10.1007/s40273-015-0268-9. Afroz A, et al. Cost-of-illness of type 2 diabetes mellitus in low and lower-middle income countries: a systematic review. BMC Health Serv Res. 2018 Dec 17;18(1):972. doi: 10.1186/s12913-018-3772-8. Dhakal K. NVivo. Journal of the Medical Library Association. 2022;110(2). doi:10.5195/jmla.2022.1271 Stephani V, Opoku D, Beran D. Self-management of diabetes in sub-Saharan africa: A systematic review. BMC Public Health. 2018;18(1). doi:10.1186/s12889-018-6050-0 Song Y., Beltran Puerta J., Medina-Aedo M., et al. Self-Management Interventions for Adults Living with Type II Diabetes to Improve Patient-Important Outcomes: An Evidence Map. Healthcare, 11(24), 3156. 2023. https://doi.org/10.3390/healthcare11243156 Beran D, Yudkin JS. Looking beyond the issue of access to insulin: What is needed for proper diabetes care in resource poor settings. Diabetes Research and Clinical Practice. 2010;88(3):217–21. doi:10.1016/j.diabres.2010.03.029 Whittemore R, Vilar-Compte M, De La Cerda S, Marron D, Conover R, Delvy R, et al. Challenges to diabetes self-management for adults with type 2 diabetes in low-resource settings in Mexico City: A qualitative descriptive study. International Journal for Equity in Health. 2019;18(1). doi:10.1186/s12939-019-1035-x Yasmin F, Ali L, Banu B, Rasul FB, Sauerborn R, Souares A. Understanding patients’ experience living with diabetes type 2 and effective disease management: A qualitative study following a mobile health intervention in Bangladesh. BMC Health Services Research. 2020;20(1). doi:10.1186/s12913-019-4811-9 Robbiati C, Armando A, da Conceição N, Putoto G, Cavallin F. Association between diabetes and food insecurity in an urban setting in Angola: A case–control study. Scientific Reports. 2022;12(1). doi:10.1038/s41598-022-04888-7 Adler AJ, Trujillo C, Schwartz L, Drown L, Pierre J, Noble C, et al. Experience of living with type 1 diabetes in a low-income country: A qualitative study from Liberia. BMJ Open. 2021;11(10). doi:10.1136/bmjopen-2021-049738 Atun R, Davies JI, Gale EA, Bärnighausen T, Beran D, Kengne AP, et al. Diabetes in sub-Saharan africa: From clinical care to health policy. The Lancet Diabetes & Endocrinology. 2017;5(8):622–67. doi:10.1016/s2213-8587(17)30181-x Beran D, Silva Matos C, Yudkin JS. The diabetes UK Mozambique Twinning Programme. results of improvements in diabetes care in Mozambique: A reassessment 6 years later using the Rapid Assessment Protocol for insulin access. Diabetic Medicine. 2010;27(8):855–61. doi:10.1111/j.1464-5491.2010.03053.x Flood D, Seiglie JA, Dunn M, Tschida S, Theilmann M, Marcus ME, et al. The state of diabetes treatment coverage in 55 low-income and middle-income countries: A cross-sectional study of nationally representative, individual-level data in 680102 adults. The Lancet Healthy Longevity. 2021;2(6). doi:10.1016/s2666-7568(21)00089-1 Tusubira AK, Akiteng AR, Nakirya BD, Nalwoga R, Ssinabulya I, Nalwadda CK, et al. Accessing medicines for noncommunicable diseases: Patients and Health Care Workers’ experiences at public and private health facilities in Uganda. PLOS ONE. 2020;15(7). doi:10.1371/journal.pone.0235696 PATH. Journey of the Pill: Findings of the NCD Commodity Supply Chain Assessment in Kenya. Seattle: PATH; 2020. Justin-Temu M, Nondo RSO, Wiedenmayer K, Ramaiya KL, Teuscher A. Anti-diabetic drugs in the private and public sector in Dar es Salaam, Tanzania. East African Medical Journal. 2010;86(3). doi:10.4314/eamj.v86i3.54962 Castillo-Laborde C, Hirmas-Adauy M, Matute I, Jasmen A, Urrejola O, Molina X, Awad C, Frey-Moreno C, Pumarino-Lira S, Descalzi-Rojas F, Ruiz TJ, Plass B. Barriers and Facilitators in Access to Diabetes, Hypertension, and Dyslipidemia Medicines: A Scoping Review. Public Health Rev. 2022 Sep 2;43:1604796. doi: 10.3389/phrs.2022.1604796. PMID: 36120091; PMCID: PMC9479461. Wudil AH, Usman M, Rosak-Szyrocka J, Pilař L, Boye M. Reversing years for Global Food Security: A review of the food security situation in sub-Saharan africa (SSA). International Journal of Environmental Research and Public Health. 2022;19(22):14836. doi:10.3390/ijerph192214836 Juarez LD, Presley CA, Howell CR, Agne AA, Cherrington AL. The Mediating Role of Self-Efficacy in the Association Between Diabetes Education and Support and Self-Care Management. Health Education & Behavior. 2022;49(4):689-696. doi:10.1177/10901981211008819 Masupe T, Onagbiye S, Puoane T, Pilvikki A, Alvesson HM, Delobelle P. Diabetes self-management: A qualitative study on challenges and solutions from the perspective of South African patients and health care providers. Global Health Action. 2022;15(1). doi:10.1080/16549716.2022.2090098 Leung CL, Naert M, Andama B, et al. Human-centered design as a guide to intervention planning for noncommunicable diseases: the BIGPIC study from Western Kenya. BMC Health Serv Res. 2020 May 12;20(1):415. doi: 10.1186/s12913-020-05199-1. Erratum in: BMC Health Serv Res. 2020 Aug 12;20(1):738. doi: 10.1186/s12913-020-05345-9. PMID: 32398131; PMCID: PMC7218487. Aifah A, Okeke NL, Rentrope CR, et al. Use of a human-centered design approach to adapt a nurse-led cardiovascular disease prevention intervention in HIV clinics. Prog Cardiovasc Dis. 2020 Mar-Apr;63(2):92-100. doi: 10.1016/j.pcad.2020.02.013. Epub 2020 Feb 21. PMID: 32092444; PMCID: PMC7237285. Blynn E, Harris E, Wendland M, et al. Integrating Human-Centered Design to Advance Global Health: Lessons From 3 Programs. Glob Health Sci Pract. 2021 Nov 29;9(Suppl 2):S261-S273. doi: 10.9745/GHSP-D-21-00279. PMID: 34845049; PMCID: PMC8628497. Mayega RW, Etajak S, Rutebemberwa E, Tomson G, Kiguli J. ‘Change means sacrificing a good life’: Perceptions about severity of type 2 diabetes and preventive lifestyles among people afflicted or at high risk of type 2 diabetes in Iganga Uganda. BMC Public Health. 2014;14(1). doi:10.1186/1471-2458-14-864 Hjelm K, Nambozi G. Beliefs about health and illness: A comparison between Ugandan men and women living with diabetes mellitus. International Nursing Review. 2008;55(4):434–41. doi:10.1111/j.1466-7657.2008.00665.x Baumann LC, Frederick N, Betty N, Jospehine E, Agatha N. A demonstration of peer support for Ugandan adults with type 2 diabetes. International Journal of Behavioral Medicine. 2014;22(3):374–83. doi:10.1007/s12529-014-9412-8 Nielsen J, Bahendeka SK, Bygbjerg IC, Meyrowitsch DW, Whyte SR. Accessing diabetes care in rural Uganda: Economic and Social Resources. Global Public Health. 2016;12(7):892–908. doi:10.1080/17441692.2016.1172100 Footnotes 1 Accredited Drug Dispensing Outlets (ADDOs) are qualified drug retail outlets established through public‒private partnerships with the government in Tanzania to maintain standards while increasing access to pharmaceutical sales points. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 07 Mar, 2026 Reviewers agreed at journal 28 Feb, 2026 Editor assigned by journal 03 Feb, 2026 Reviewers agreed at journal 04 Dec, 2025 Reviewers invited by journal 03 Dec, 2025 Submission checks completed at journal 22 Nov, 2025 First submitted to journal 22 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7707279","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":555252674,"identity":"e9f9258e-cfcb-4e70-99bf-cdc7229c06a6","order_by":0,"name":"Siri Wood","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAq0lEQVRIiWNgGAWjYLACngogIUGaljNATJoW3jZStMjPSD744O28O/L20g2Mjyt+EaHF4EZasuHcbc8Me2QOMBue7SNGi3SOmTTvtsOMPRIJbJKNPcQ4bDZIy5zD9sRrYbgN0tJwOBGspeEHMQ67/yzZcM6xZ8k9NxKbDRsbiHFYz+GDD97U3LFtBwbdw4Y/xDgMAg4AMWMDA2MbaVpAgARbRsEoGAWjYOQAABP1OHvNazOiAAAAAElFTkSuQmCC","orcid":"","institution":"PATH USA","correspondingAuthor":true,"prefix":"","firstName":"Siri","middleName":"","lastName":"Wood","suffix":""},{"id":555252675,"identity":"59b20e7f-1066-4570-bbbd-71eb0bb4517b","order_by":1,"name":"Laura Meyer","email":"","orcid":"","institution":"PATH USA","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Meyer","suffix":""},{"id":555252679,"identity":"f0242490-0c41-4cec-bfe8-39b3e1e831f8","order_by":2,"name":"Lindsay Rubin","email":"","orcid":"","institution":"PATH USA","correspondingAuthor":false,"prefix":"","firstName":"Lindsay","middleName":"","lastName":"Rubin","suffix":""},{"id":555252680,"identity":"2a34859e-4051-4f79-83e8-c9cd54d16be2","order_by":3,"name":"Gerald Robi","email":"","orcid":"","institution":"PATH Tanzania","correspondingAuthor":false,"prefix":"","firstName":"Gerald","middleName":"","lastName":"Robi","suffix":""},{"id":555252681,"identity":"2c84a936-b30f-4577-a241-a6c7564a2577","order_by":4,"name":"Geraldo Sitoe","email":"","orcid":"","institution":"PATH Mozambique","correspondingAuthor":false,"prefix":"","firstName":"Geraldo","middleName":"","lastName":"Sitoe","suffix":""},{"id":555252682,"identity":"95f6e145-b80a-48a9-a2aa-18d08b72d5ad","order_by":5,"name":"Angela Mondlane","email":"","orcid":"","institution":"PATH Mozambique","correspondingAuthor":false,"prefix":"","firstName":"Angela","middleName":"","lastName":"Mondlane","suffix":""},{"id":555252683,"identity":"edda8d94-bcdd-45fe-9299-fa9e0a8f240a","order_by":6,"name":"Gracious Ahumuza","email":"","orcid":"","institution":"PATH Uganda","correspondingAuthor":false,"prefix":"","firstName":"Gracious","middleName":"","lastName":"Ahumuza","suffix":""},{"id":555252684,"identity":"a79edb73-43d6-4b2d-a167-eea3a6cf8388","order_by":7,"name":"Abha Patil","email":"","orcid":"","institution":"PATH USA","correspondingAuthor":false,"prefix":"","firstName":"Abha","middleName":"","lastName":"Patil","suffix":""},{"id":555252685,"identity":"e6cb705f-0f59-43cc-8e6e-ea0c8770096c","order_by":8,"name":"Ida Ndione","email":"","orcid":"","institution":"PATH Senegal","correspondingAuthor":false,"prefix":"","firstName":"Ida","middleName":"","lastName":"Ndione","suffix":""},{"id":555252686,"identity":"3346b3f4-c482-4f2c-a331-c1ee27494878","order_by":9,"name":"Cheikh Niang","email":"","orcid":"","institution":"PATH Senegal","correspondingAuthor":false,"prefix":"","firstName":"Cheikh","middleName":"","lastName":"Niang","suffix":""},{"id":555252687,"identity":"0622c4f9-1703-4750-bf04-4fd4bbc14e34","order_by":10,"name":"Helen McGuire","email":"","orcid":"","institution":"PATH USA","correspondingAuthor":false,"prefix":"","firstName":"Helen","middleName":"","lastName":"McGuire","suffix":""},{"id":555252688,"identity":"4de07f4e-4660-45f0-846d-f567fb898db9","order_by":11,"name":"Bonkana Maiga","email":"","orcid":"","institution":"PATH Senegal","correspondingAuthor":false,"prefix":"","firstName":"Bonkana","middleName":"","lastName":"Maiga","suffix":""}],"badges":[],"createdAt":"2025-09-24 23:38:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7707279/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7707279/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":97671999,"identity":"12b751cf-035f-441e-98dd-0cdef380e5b1","added_by":"auto","created_at":"2025-12-08 09:33:42","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":194865,"visible":true,"origin":"","legend":"","description":"","filename":"CarePakSupplyingsolutionsrevisedsubmission.docx","url":"https://assets-eu.researchsquare.com/files/rs-7707279/v1/ea6297d363db94b0b957a7bb.docx"},{"id":97522592,"identity":"62c4bd30-653c-4406-8772-93648b93b10a","added_by":"auto","created_at":"2025-12-05 11:33:47","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":13640,"visible":true,"origin":"","legend":"","description":"","filename":"04dba6ffdb11417c86e4dd6c10bb8e5b.json","url":"https://assets-eu.researchsquare.com/files/rs-7707279/v1/cb586eff87f196c1cc8e4464.json"},{"id":97522598,"identity":"d7930a3b-f30e-4c7f-85fa-4fdc28d560d6","added_by":"auto","created_at":"2025-12-05 11:33:47","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":101374,"visible":true,"origin":"","legend":"","description":"","filename":"04dba6ffdb11417c86e4dd6c10bb8e5b1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7707279/v1/954ecc10c8285553d130b2d9.xml"},{"id":97522593,"identity":"c05d600b-d98a-486d-b2ad-0ab9a6f4dc3e","added_by":"auto","created_at":"2025-12-05 11:33:47","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":87754,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7707279/v1/7cb4f3c35c346dac89dec405.jpeg"},{"id":97522595,"identity":"01b0960a-10a5-4c51-b282-4f84725550b3","added_by":"auto","created_at":"2025-12-05 11:33:47","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":89759,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7707279/v1/64e759a7c1aed923817002cd.png"},{"id":97522597,"identity":"c7a480e4-e4c2-41bd-a5f2-78585df42419","added_by":"auto","created_at":"2025-12-05 11:33:47","extension":"xml","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":96878,"visible":true,"origin":"","legend":"","description":"","filename":"04dba6ffdb11417c86e4dd6c10bb8e5b1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7707279/v1/803a28d08a5366f2e94fe921.xml"},{"id":97522596,"identity":"802a3a2d-c4cf-471d-89a2-6825ba87e297","added_by":"auto","created_at":"2025-12-05 11:33:47","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":114187,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7707279/v1/68fa4cbe611de030a70be75c.html"},{"id":97522590,"identity":"74e4ace6-1615-4e04-92d8-c55b244c2a83","added_by":"auto","created_at":"2025-12-05 11:33:47","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":143862,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePercentage of retail outlets reporting stockouts for individual diabetes care products at the time of the survey\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote: n= may not equal the total number of outlets surveyed because not all outlets had sufficient data collected to calculate stock and availability. ADDOs in Tanzania were included but inherently may not generally offer as many supplies as larger outlets do.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7707279/v1/b2329c296b94aa34b21fdfef.jpg"},{"id":97522591,"identity":"59906f01-88cf-416b-a003-4e606cc1ac9b","added_by":"auto","created_at":"2025-12-05 11:33:47","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":122466,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHCD kit development process\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7707279/v1/e59c0e682e0d26f353c6a635.jpg"},{"id":97677816,"identity":"55bad012-92d4-49ab-bb75-fa73ee90b922","added_by":"auto","created_at":"2025-12-08 09:54:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1596999,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7707279/v1/5ad2ee3f-8ebf-47f2-a0ac-2847f8694c7c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Supplying solutions: A mixed-methods study on experiences with access to diabetes care supplies in four African countries to inform the development of a bundled solution for improved self-care and clinical management","fulltext":[{"header":"Background","content":"\u003cp\u003eRecent evidence suggests that 1.3 billion people will have diabetes by 2050, with 80% living in low- and middle-income countries (LMICs).\u003csup\u003e1,2,3\u003c/sup\u003e To meet the World Health Organization\u0026rsquo;s target of 100% of people living with diabetes (PLWD) having access to affordable insulin and blood glucose self-monitoring by 2030, it is crucial to identify and address individual, social, and health system factors that challenge effective disease management.\u0026nbsp;\u003csup\u003e4,5,6\u003c/sup\u003e Many PLWD in LMICs face barriers such as stockouts and high out-of-pocket costs, which prevent them from acquiring the medicines and products needed to measure blood glucose (glucometers, test strips, lancets) or safely administer insulin (needles and syringes). This inconsistent access to insulin and supplies leads to serious consequences when PLWD are unable to monitor their blood sugar levels, must ration medication or test strips, or reuse insulin syringes.\u003csup\u003e7,8\u003c/sup\u003e Rationing leads to increased pain due to the dulling of needles and increases the risk of infection, hyperglycemia or hypoglycemia, and long-term complications such as amputation, blindness, kidney failure, and death. Associated morbidity also causes substantial economic losses to PLWD, their families, health systems, and national economies through direct medical costs and loss of wages.\u003csup\u003e9,10\u003c/sup\u003e This unmet need is a call for innovation in service delivery and improved access to self-care supplies to support better clinical management.\u003c/p\u003e\n\u003cp\u003eThis publication outlines the findings of a landscape assessment and retail outlet survey conducted between 2022 and 2024 in collaboration with ministries of health in four countries\u0026mdash;Mali, Mozambique, Tanzania, and Uganda\u0026mdash;to understand diabetes self-care and management practices, barriers to and facilitators of care, retail costs, and access to medicines and supplies. These countries were selected based on donor and government interest in advancing diabetes supply initiatives. The study identified key obstacles and enablers related to accessing diabetes self-care supplies and informed the development of a prototype kit for diabetes management supplies in each country. The landscape and retail outlet survey findings underscore the critical issues of the accessibility and affordability of supplies, highlight the significant need for education on nutrition and disease management, and outline the essential commodities that could be bundled to improve self-care. Following the landscape and retail outlet survey, PATH brought together PLWD and other stakeholders in human-centered codesign workshops to develop Diabetes CarePak, a bundled solution designed to increase access and affordability, facilitate self-care and clinical management of blood glucose, and improve quality of life.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy aims\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePATH conducted a mixed-methods study in Mali, Mozambique, Tanzania, and Uganda between November 2022 and January 2024 to understand the health care journey of PLWD, identify the costs and barriers to accessing supplies necessary for safe insulin administration and diabetes self-management, and inform the development of Diabetes CarePak. More broadly, the CarePak project aims to demonstrate the benefits and cost-effectiveness of CarePak to the health system, advocate for national health coverage to support broader uptake, and improve access to safe insulin administration by increasing the availability of supplies. User testing, health impact data, and cost-effectiveness analysis are reported in separate publications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study comprised three parts: semi-structured, in-depth individual interviews with PLWD, health care workers (HCWs), and stakeholders; a quantitative survey of retail outlets and pharmacies; and human-centered design workshops to develop CarePak. The study adhered to the ethical principles of the Declaration of Helsinki, including administration and obtention of informed consent for all participants.\u0026nbsp;Several complementary focus group discussions (FGDs) were conducted with PLWD in Mozambique, Tanzania, and Uganda. No FGDs were conducted in Mali due to time and resource constraints. The retail outlet survey included private and government-owned pharmacies across the participating districts. It documented the availability and prices of commonly used supplies for insulin administration and blood glucose monitoring, including syringes, glucometers, test strips, and alcohol swabs. Findings from the landscape survey informed the development of a Diabetes CarePak prototype through codesign workshops, as well as educational materials for PLWD and training materials for HCWs. The Diabetes CarePak is a bundled solution developed to improve access to supplies necessary for safe insulin administration and self-care, enhancing quality of life and diabetes-related health outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSite selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBy working with the ministry of health (MOH) in each country, study sites were selected to optimize geographic representation, including rural and urban areas, prioritizing facilities with high patient volume, functional patient databases, and a mix of public, private, and faith-based facilities (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Distribution of study sites by region and country\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBamako Commune IV\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"662\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProvince/region and district\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 348px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of facilities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\u003cstrong\u003e\u0026nbsp;Mali\u003c/strong\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMozambique\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTanzania\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUganda\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003eBamako Commune IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003eBamako Commune VI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003eKoulikoro\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003eSikasso\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003eMaputo Province (Maputo City)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003eNampula Province (Nampula City)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003eKilimanjaro (Same District)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003eDar es Salaam (Ubongo Municipal Council)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003eKigoma (Kigoma District Council)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003eMwanza (Nyamagana Municipal Council)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003eEastern Region (Namutumba District)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003eEastern Region (Jinja District)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003eEastern Region (Mbale District)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants and sampling strategy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePurposive sampling was used to recruit individuals aged 18 to 70 years with a diagnosis of type 1 or type 2 diabetes mellitus (T1D or T2D) who had been taking insulin or other treatment for more than six months, as well as HCWs with primary responsibility for providing diabetes-related care at the participating facilities.\u0026nbsp;No formal power calculation was conducted, as the study focused on describing experiences and access to supplies. For interviews with PLWD, data saturation was reached after 15-20 interviews, as interview transcripts beyond that point revealed no new codes or themes related to participant experiences. A large sample was retained so as to account for differences in experiences of participants between gender, age, and across urban and rural sites (Table 3). Participants were recruited from medical records or outpatient clinic waiting rooms. Informed consent was obtained from all participants. Stakeholders who participated in the codesign workshops included PLWD, HCWs, MOH representatives, and staff from local patient support associations, all of which were purposively selected to ensure diverse perspectives.\u003c/p\u003e\n\u003cp\u003eA survey of medical retail outlets in the participating districts was conducted to assess the availability and cost of common diabetes management supplies. The outlets included private pharmacies and government-owned pharmacies co-located at health facilities, with numbers varying by setting on the basis of available time and resources (Table 2). The types of outlets reflect the categories used in each country during data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Number and type of retail outlets surveyed by country\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"474\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutlet type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eMali (n=32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003ePublic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eMozambique (n=36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003ePublic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eTanzania (n=70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eADDO\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eHealth facility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003ePharmacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eUganda (n=12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eHealth facility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003ePharmacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: The number of outlets surveyed reflects the\u0026nbsp;time and resource constraints in each setting. The outlet types shown are based on the categories used during data collection in each country.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection and analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSemi-structured qualitative guides were used to interview PLWD, HCWs, and other stakeholders, and a list of possible supplies was used to identify participants\u0026rsquo; preferences for items to be included in CarePak. The interviews were conducted in local languages (Bambara in Mali, Portuguese in Mozambique, Swahili in Tanzania, and Lugisu or Lusoga in Uganda), audio-recorded, transcribed, and translated into English. FGDs and in-depth interviews (IDIs) were conducted at health facilities or other spaces that provided auditory privacy. Data collection took place between October 2022 and April 2023, except in Mali, where it occurred in January 2024.\u003c/p\u003e\n\u003cp\u003eAn initial coding framework was developed, and the interview transcripts were coded via NVivo v14 software.\u003csup\u003e11\u003c/sup\u003e A thematic approach was applied to analyze the transcripts, explore patterns in the data, and contextualize findings with literature. We used a combined inductive and deductive approach to code development, beginning with a set of codes derived from theory. During analysis, we looked for new codes that emerged from insights in the data to refine, expand, or modify the initial framework. To ensure consistency, coding was led by one individual with oversight by, and discussion with, other team members at periodic check ins during the analysis process.In each country, PATH staff trained in human-centered design (HCD) facilitated interactive workshops to cocreate prototype CarePak kits with PLWD and HCWs. During the workshops, the participants engaged in creative exercises, including brainstorming and card-sort ranking, and were provided with a range of materials (paper, cardboard, tape, objects of various shapes and sizes) to create low-fidelity physical prototypes of their desired CarePak. Participant feedback guided item selection and organization in kits, reflecting items that participants identified as necessary and most useful. Health care supplies were then procured to assemble a high-fidelity prototype CarePak for validation with MOH representatives. Data from the retail outlet survey were tabulated and reviewed in Excel to describe the availability, costs, and colocation of diabetes-related products at retail sites.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Western Institutional Review Board (WIRB)-Copernicus Group Institutional Review Board (WCG IRB) in the United States (June 8, 2022); the Mildmay Uganda Research Ethics Committee (MUREC) (August 29, 2022); the Uganda National Council for Science and Technology (UNCST) (October 11, 2022); the Tanzania National Institute for Medical Research (NIMR) (September 2, 2022); the Mozambique Comit\u0026eacute; National da Bio\u0026eacute;tica para a Sa\u0026uacute;de (CNBS) (December 15, 2022); and the Comit\u0026eacute; National d\u0026rsquo;\u0026Eacute;thique pour la Sant\u0026eacute; et les Sciences de la Vie (CNESS) in Mali (May 8, 2023).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eA total of 498 individuals participated in the study. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the number of IDIs and FGDs conducted in each country.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eNumber of participants by category and by country\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMali\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMozambique\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTanzania\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eUganda\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eIndividual interviews\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePLWD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e137\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e277\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHCWs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e43\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStakeholders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e18\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePharmacy staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e78\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFocus group discussions\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePLWD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22 (3 FGDs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14 (2 FGDs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e46 (2 FGDs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e82 \u003cb\u003e(7 FGDs)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e*The number of participants interviewed varied by country based on available budget, time, and human resources in each setting.\u003c/p\u003e\u003cp\u003eAmong the 277 PLWD interview participants, 60% were female, and 40% were male. The average age of the PLWD participants was 55 years. In Mozambique, Tanzania, and Uganda, 18% had T1D, 74% had T2D, and 8% did not know their type. In Mali, 99% of the patients had T1D.\u003c/p\u003e\u003cp\u003eThe results are organized around the three components of the study: qualitative interviews and focus group discussions, the retail outlet survey, and the cocreation workshops. Together, these findings provide a holistic view of the barriers faced by PLWD and directly inform the design of the CarePak integrated care package.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eQualitative IDIs and FGDs with PLWD\u003c/h2\u003e\u003cp\u003e The study team conducted IDIs and FGDs to explore the health care journeys and personal experiences of PLWD. The topics explored included participants\u0026rsquo; reactions to their diagnosis, social support, self-management practices such as medication adherence and blood glucose testing, accessibility and affordability of diabetes medication and supplies, knowledge about diabetes and disease management, and diet and nutrition.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eDiagnosis experiences and social support\u003c/h2\u003e\u003cp\u003eA common complicating factor during the initial diabetes diagnosis for many PLWD is symptom overlap with other infectious diseases, such as malaria, tuberculosis, and HIV. Two-thirds of the participants reported having other health conditions associated with diabetes, most commonly hypertension (more than half), cardiovascular disease, and nonhealing ulcers or wounds (a significant minority). A minority of participants reported being HIV positive.\u003c/p\u003e\u003cp\u003eNearly half of the participants across all countries experienced negative reactions to their diabetes diagnosis, including anxiety, fear, or worry. Approximately one in four participants reported having a mixed or neutral reaction, whereas a minority said they were happy to finally have a confirmed diagnosis. Negative reactions were more likely among individuals who lacked social support, faced financial hardship, lost a loved one to diabetes complications, or were living with a comorbidity. Those who had received counseling or health education from a health provider reported responding more positively to their diagnosis.\u003c/p\u003e\u003cp\u003eMany participants reported that emotional support from other PLWD, health care providers, and their loved ones strengthened their motivation for self-care. Over half of the participants reported that a family member accompanied them to a health facility when they felt unwell. Participants in Mozambique reported more social support resources than those in other countries did, citing involvement with the Mozambican Diabetes Association (AMODIA) support group program. A minority of Tanzanian participants also reported being part of a support group.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eDiabetes self-management\u003c/h2\u003e\u003cp\u003e The study participants identified the three most challenging aspects of self-management as follows: 1) taking medicines as directed, 2) monitoring blood glucose levels, and 3) following dietary guidelines, primarily because of the high cost and limited availability of diabetes medication and care supplies, as well as food insecurity. The participants reported that the high cost of glucometers and limited access to affordable test strips and lancets were the major barriers to testing their blood glucose regularly at home. Approximately one-third of the participants across all four countries said that they owned a glucometer but could no longer use it because matching test strips were unavailable or out of stock at public and private pharmacies. Nearly all the participants said that they wanted reliable access to glucometers and supplies to test their blood glucose at home and improve monitoring.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I go to the hospital for blood sugar tests; I don\u0026rsquo;t have a testing machine. I test every two days, and I pay for it. I don\u0026rsquo;t have health insurance, and the cost of injections is too high.\u0026rdquo;\u003c/em\u003e \u0026ndash; Male PLWD in Tanzania, age 46\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Going to the health center to measure my blood glucose is tiring, and I need my children to help me administer my medication.\u0026rdquo; \u0026ndash;\u003c/em\u003e Female PLWD in Mali, age 55\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eAccessibility and affordability of medication and supplies\u003c/h2\u003e\u003cp\u003eAcross all countries, financial hardship and the high cost of medication were significant barriers to diabetes management for nearly all participants, limiting their ability to consistently buy and take insulin and oral medications as directed. Participants across all study countries reported needing help from a relative to pay for medication, either periodically or regularly. This was often due to disability, unemployment, or underemployment. The participants reported frequent stockouts of injectable and oral medications at hospital- and clinic-based pharmacies, whereas private pharmacies had fewer stockouts but charged more, making them less affordable. Consistent with these qualitative reports from PLWD, significant stockouts of supplies were documented in the retail outlet survey reported below.\u003c/p\u003e\u003cp\u003ePLWD using insulin stated that they were prescribed an average of 15 syringes per month and typically reused each syringe at least twice. Many participants reported reusing a single syringe for several days or up to a week before discarding it. The participants said that procuring supplies often required visiting multiple locations, creating a financial burden due to transport costs and lost income from time away from work.\u003c/p\u003e\u003cp\u003eMany participants reported that having diabetes added a financial burden on their family or household due to the ongoing costs of treatment and lifestyle changes.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It has happened before when I was unable to buy medicine for a week. I got sick, and my blood sugar went up a lot. I was hospitalized when I couldn\u0026rsquo;t afford it. There is no one to help me but myself because my mother is sick, and she had a stroke.\u0026rdquo;\u003c/em\u003e \u0026ndash; Female PLWD in Tanzania, age 39\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My son helps me. When I don\u0026rsquo;t have money while I have a prescription\u0026mdash;for example, today I have to buy medication and I haven\u0026rsquo;t received it yet\u0026mdash;when he has money, he\u0026rsquo;ll give it to me to buy.\u0026rdquo;\u003c/em\u003e \u0026ndash; Female PLWD in Mozambique, age 65\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eCost of transportation and distance to medical treatment or pharmacy\u003c/h2\u003e\u003cp\u003eMost participants said that transportation costs were another financial burden. Factors contributing to transportation costs included frequent appointments, distance to hospitals or clinics, and whether medications and supplies could be obtained at the hospital or local pharmacy. Half of the participants traveled for at least 45 minutes to reach the clinic, often using public transportation, which added to their costs. Participants who traveled farther to a clinic or a pharmacy cited time and transport costs as barriers to medication adherence. Several participants reported walking to their appointments due to a lack of money for transportation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes, to come to the hospital, I have to save money for three weeks so I can have money for a minibus. If I don\u0026rsquo;t do that, that day will come, and I won\u0026rsquo;t be able to go to the appointment because I don\u0026rsquo;t have the money.\u0026rdquo;\u003c/em\u003e \u0026ndash; Female PLWD in Mozambique, age 62\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s two hours to go and return. It disturbs me, yes, because if medication were available, the time I am using to search for medicines, there are customers waiting for me.\u0026rdquo;\u003c/em\u003e \u0026ndash; Female PLWD in Tanzania, age 24\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eKnowledge and education about diabetes\u003c/h2\u003e\u003cp\u003ePLWD identified several areas of diabetes management that they wanted to learn more about, especially diet and nutrition. Most participants reported receiving basic dietary advice at diagnosis but wanted more detailed information on diabetes-friendly diets, including how to balance their diets with a limited budget and adjust their eating habits based on fluctuating blood glucose levels. PLWD also wanted to learn how to prevent diabetes, teach family members about it, and understand the difference between T1D and T2D.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I would like to get more education about the proper diet for diabetic patients, the right time to eat, and how to plan foods, because there are many misconceptions that confuse diabetic patients.\u0026rdquo;\u003c/em\u003e Male PLWD in Tanzania, age 21\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Alternative ways of using certain products\u0026mdash;for example, if I don\u0026rsquo;t have sorghum, what can I use as an alternative? If I don\u0026rsquo;t have olive oil, what can I use as an alternative because oil is no longer available?\u0026rdquo;\u003c/em\u003e \u0026ndash;\u0026ndash;PLWD in Mozambique, age 39, gender not recorded\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eDietary practices\u003c/h2\u003e\u003cp\u003eAcross all four countries, nearly all participants reported that they had made changes in their diets and eating habits since being diagnosed with diabetes, such as cutting back on oil, fatty meats, sugary drinks, starches, or dairy. Common dietary challenges reported by participants included eating separately from other family members or depending on others to cook for them (in-laws, spouses, etc.). Most said that diet changes were financially burdensome, as they could not afford the recommended foods to replace high-glycemic foods (e.g., olive oil). Some individuals reported eating very little or skipping meals when they lacked access to low-glycemic foods. HCWs confirmed that financial challenges affect PLWD\u0026rsquo;s dietary choices.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Here, many people die from this disease because of the lack of conditions; food is also part of the aggravation of the disease itself. If they tell you that you can\u0026rsquo;t eat this and you don\u0026rsquo;t have anything else at home, you have to eat to relieve your hunger.\u0026rdquo;\u003c/em\u003e \u0026ndash; Male PLWD in Mozambique, age 56\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t go to parties anymore..., as there are only things I don\u0026rsquo;t eat. It\u0026rsquo;s not normal to go to a party and have to take your lunchbox with you. For other people, it\u0026rsquo;s already a nuisance\u0026mdash;you just come to talk, and you don\u0026rsquo;t eat, and you don\u0026rsquo;t do anything else\u0026mdash;so it\u0026rsquo;s better not to go.\u0026rdquo;\u003c/em\u003e \u0026ndash; Female PLWD in Mozambique, age 49\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eRetail outlet survey\u003c/h2\u003e\u003cp\u003eBuilding on the barriers identified in the interviews and focus groups, the retail survey assessed the availability and retail prices of essential diabetes supplies to evaluate access to and affordability in local markets. The retail survey identified frequent stockouts of supplies, price variability within and across countries, and low rates of colocation of insulin with other diabetes supplies. The survey thus quantified and reinforced key qualitative themes\u0026mdash;particularly those concerning inconsistent supply, affordability barriers, and the burden of traveling to multiple outlets.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eStockouts and availability\u003c/h2\u003e\u003cp\u003eThe survey revealed regular stockouts of essential diabetes supplies in all four countries, especially glucometers, test strips, and sharps containers. Alcohol bottles were consistently available, reflecting their utility in general health care, whereas alcohol swabs showed striking shortages\u0026mdash;especially in Mali (100%) and Tanzania (95%)\u0026mdash;likely due to alternative disinfection methods (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eNote\u003c/strong\u003e\u003cp\u003e\u003cem\u003en\u0026thinsp;=\u0026thinsp;may not equal the total number of outlets surveyed because not all outlets had sufficient data collected to calculate stock and availability. ADDOs in Tanzania were included but inherently may not generally offer as many supplies as larger outlets do.\u003c/em\u003e\u003c/p\u003e\u003c/p\u003e\u003cp\u003eStockout rates for blood lancets ranged from 33% in Uganda to 80% in Tanzania. Mozambique (42%) and Mali (48%) showed moderate unavailability. Glucometers had high unavailability rates across all countries, with Tanzania (57%) experiencing the highest stockout, followed by Uganda (42%), Mozambique (33%), and Mali (29%). Test strips showed similar levels of unavailability, ranging from 32% in Mali to 42% in Uganda. Insulin syringe stockouts varied, with Mali (3%) reporting the lowest stockout rate and Uganda (42%) and Tanzania (26%) experiencing the highest shortages. Insulin vials were entirely unavailable in Mali (100%), underscoring systemic barriers to stocking insulin alongside other essential diabetes supplies. Other countries faced similar challenges, with unavailability ranging from 42% in Uganda to 67% in Mozambique. Insulin pens were generally less available, aligning with global trends, except in Mali, where only pens were stocked, highlighting a unique deviation.\u003c/p\u003e\u003cp\u003eThe patterns of stockouts revealed by the survey provide important context for understanding the affordability and access issues reported by PLWD, which are further explored in the pricing analysis below.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003ePricing\u003c/h2\u003e\u003cp\u003eThe survey documented the retail prices for the average number of unbundled supplies required monthly for safe insulin injection and blood glucose testing (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The product quantities represent a month\u0026rsquo;s worth of standard diabetes care supplies, similar to the \u0026ldquo;Diabetes CarePak Insulin Starter Kit.\u0026rdquo; The CarePak kit includes 100 grams of cotton wool and either a 100 mL bottle of alcohol or 50 alcohol swabs for hygiene and injection site preparation. For blood glucose monitoring, the kit contains a glucometer, 50 test strips, and 50 lancets for consistent and accurate glucose self-monitoring. It also includes 30 insulin syringes to support daily insulin administration, although this may not fully meet all needs for PLWD. Although insulin vials and pens are excluded from the bundle, the quantities are standardized to represent a month\u0026rsquo;s supply for a PLWD: one 10 mL vial of insulin and one insulin pen. This standardized approach allows for comparisons across countries.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAverage retail purchase price for unbundled supplies required monthly for safe insulin administration\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"11\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eMali\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eMozambique\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eTanzania\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003eUganda\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u003cp\u003eAll countries\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIncluded in CarePak\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAverage\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAverage\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eAverage\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eAverage\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eAverage\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlcohol bottle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e41\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e31\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003e$1.05\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e76\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e0.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003e9\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003e$0.57\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cem\u003e157\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u003cem\u003e$0.88\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlcohol swabs*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e16\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e3\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e3.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003e7\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cem\u003e26\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1.77\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood lancet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e17\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e8.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e23\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e8.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e9\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e3.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003e8\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e9.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cem\u003e57\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e8.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCotton wool\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e65\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e2.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e31\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003e$1.66\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e155\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003e10\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003e$0.89\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cem\u003e261\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u003cem\u003e$1.40\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGlucometer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e41\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e33.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e24\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e41.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e28\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e19.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003e18\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e17.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cem\u003e111\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e29.59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGlucose test strips\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e39\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e27.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e23\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e21.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e51\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e7.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003e18\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e13.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cem\u003e131\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e16.59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInsulin syringe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e36\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e6.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e29\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e7.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e31\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e5.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003e8\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e6.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cem\u003e104\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e6.65\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSharps container**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e2\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e4.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e15.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cem\u003e4\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e7.95\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal price of commodities\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cb\u003e$84.29\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u003cb\u003e$81.03\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003cb\u003e$55.02\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e\u003cb\u003e$46.71\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u003cp\u003e\u003cb\u003e$70.56\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eExcluded from CarePak\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInsulin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e84\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e8.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e12\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e20.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e55\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e7.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003e19\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e7.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cem\u003e170\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e8.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInsulin pen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e28\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e64.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e9\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e25.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e3\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e10.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003e8\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e10.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cem\u003e48\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e45.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e*Owing to overlap in use cases, the price of alcohol swabs was excluded from the total price of the commodities bundle in Mali. The price of alcohol bottles and cotton wool was excluded from the total price of the commodities bundle in Mozambique, Tanzania, and Uganda.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e**The price of sharps containers was excluded from Mozambique and Uganda because of a lack of data.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe prices of general consumables\u0026mdash;cotton wool (100 g), alcohol bottles (100 mL), alcohol swabs (50), and blood lancets (50)\u0026mdash;varied widely across countries but showed consistent trends in cost drivers. Tanzania had the lowest prices overall, whereas Mozambique presented the greatest variability and highest outliers. Cotton wool is relatively inexpensive and widely accessible across countries. The number of alcohol bottles used ranged from \u003cspan\u003e$\u003c/span\u003e0.04 to \u003cspan\u003e$\u003c/span\u003e4.61, with Mali reporting the highest average price (\u003cspan\u003e$\u003c/span\u003e1.63). Instead of purchasing both separately, PLWDs could opt for alcohol swabs, which were slightly more expensive, with Mozambique reporting an average of \u003cspan\u003e$\u003c/span\u003e1.85. Lancet prices varied widely, peaking at \u003cspan\u003e$\u003c/span\u003e61.02 in Uganda, with an average of \u003cspan\u003e$\u003c/span\u003e8.00 across all countries. These price outliers suggest supply chain inefficiencies in some regions. Data for sharps containers were limited, with an average cost of \u003cspan\u003e$\u003c/span\u003e7.95 reported. Limited data suggest alternative\u0026mdash;and possibly improper\u0026mdash;shared disposal methods across countries.\u003c/p\u003e\u003cp\u003eThe average cost for insulin syringes (30 syringes) across countries was \u003cspan\u003e$\u003c/span\u003e6.65. Prices varied widely across countries, with Mozambique reporting the highest average cost of \u003cspan\u003e$\u003c/span\u003e7.80. In-country price variability was greatest in Tanzania, with prices ranging from \u003cspan\u003e$\u003c/span\u003e1.29 to \u003cspan\u003e$\u003c/span\u003e25.79.\u003c/p\u003e\u003cp\u003eThe single-unit price for glucometers ranged widely, with averages from \u003cspan\u003e$\u003c/span\u003e19.50 in Tanzania to \u003cspan\u003e$\u003c/span\u003e41.36 in Mozambique. Mali reported the highest price at \u003cspan\u003e$\u003c/span\u003e102.54. Despite being a one-time investment, the high upfront cost can be a barrier to adoption. Test strips (30 strips) were a recurring expense, averaging from \u003cspan\u003e$\u003c/span\u003e7.40 in Tanzania to \u003cspan\u003e$\u003c/span\u003e27.47 in Mali.\u003c/p\u003e\u003cp\u003eInsulin vials and pens were excluded from the bundle price, but colocation with other supplies remains critical for safe and consistent use. Prices for insulin vials (10 mL) were more stable, averaging from \u003cspan\u003e$\u003c/span\u003e7.31 in Tanzania to \u003cspan\u003e$\u003c/span\u003e20.04 in Mozambique. Across all countries, the average price was \u003cspan\u003e$\u003c/span\u003e8.57, highlighting the importance of streamlined procurement to ensure affordability. The cost of insulin pens varied significantly, from an average of \u003cspan\u003e$\u003c/span\u003e10.88 in Uganda to \u003cspan\u003e$\u003c/span\u003e64.86 in Mali. These disparities reflect variations in market dynamics, distribution, and competition.\u003c/p\u003e\u003cp\u003eThe pricing and availability challenges documented in the retail survey, combined with the access barriers described in the interviews and focus groups, underscore the need for a bundled diabetes care solution. This led to cocreation workshops aimed at developing the CarePak prototype to improve supply access and self-management. These pricing data directly mirror the affordability challenges described by PLWD in interviews\u0026mdash;where participants reported rationing medication, reusing syringes, and skipping glucose testing due to unaffordable supplies. For instance, the high costs of glucometers and test strips observed in Mali and Mozambique correspond to participant accounts of discontinued home testing, while lower relative prices in Tanzania may explain slightly greater testing consistency reported there.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eKit design and cocreation workshops\u003c/h2\u003e\u003cp\u003eBetween February and April 2023, PATH held cocreation workshops in Mozambique, Tanzania, and Uganda with PLWD (n\u0026thinsp;=\u0026thinsp;29) and HCWs (n\u0026thinsp;=\u0026thinsp;11) to envision an essential package of diabetes management supplies through a series of exercises. The supply kit would ideally enable users to track daily blood glucose levels to share with medical providers, supporting better clinical decision-making and care. After discussing availability and other challenges identified in the landscaping interviews, attendees designed a low-fidelity CarePak prototype containing the desired supplies. The participants used cardboard cutouts to visualize different bundle configurations. The final approved products were then purchased and assembled to create a high-fidelity prototype, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eDuring these workshops, the study team proposed content for an HCW training curriculum and an education booklet for PLWD, which was based on earlier versions developed by PATH in Kenya and incorporated input from participants interviewed during the landscaping phase. These materials were adapted to each country\u0026rsquo;s context and aligned with national diabetes management guidelines. PATH then convened stakeholder meetings to validate the kit components. The cocreation workshops and validation meetings resulted in a prototype kit tailored to each country. Four CarePak versions were developed: a starter kit and a monthly refill kit for both insulin and oral medication users. Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e presents the contents of the four kit configurations.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eKit contents and commodity quantities\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eKit item\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eInsulin kits\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eOral medication kits\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStarter kit\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRefill kit\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStarter kit\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRefill kit\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGlucometer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTest strips\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLancets\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlcohol swabs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInsulin syringes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSharps container\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood glucose log\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation booklet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStorage box or bag\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAlthough some programs address access to insulin and essential supplies in sub-Saharan Africa, little evidence exists on holistic diabetes self-management interventions or on the qualitative factors shaping self-care.\u0026nbsp;As LMIC health care systems invest more in noncommunicable diseases, understanding the individual, social, and system-level influences on diabetes management is essential. \u003csup\u003e12,13\u003c/sup\u003e In this study, IDIs, FGDs and a retail survey highlighted how supply shortages, economic strain, and limited education constrain daily self-management. This assessment also identified essential commodities that could be bundled to improve access. Four standardized kits were co-designed during workshops with PLWD, which PATH tested with users in each country (the results are reported separately).\u003c/p\u003e\n\u003cp\u003eLimited accessibility and affordability of diabetes supplies and medications emerged as the most significant barriers across all countries. Participants\u0026rsquo; accounts reflected prior findings that supply unavailability and high costs undermine health and financial security of PLWD and their families.\u003csup\u003e6,7\u003c/sup\u003e Many described being inconsistent access glucometers and testing supplies, with brand-matched test strips and reagents further restricting use.\u003csup\u003e\u0026nbsp;6, 17,21\u003c/sup\u003e Retail data corroborates these experiences, showing frequent stockouts and wide pricing disparities; in areas with the highest prices or lowest availability, participants often relied on clinics for testing or went without monitoring.\u003cem\u003e\u0026nbsp;\u003c/em\u003eFinancial hardship and food insecurity also limited participants\u0026rsquo; ability to monitor blood glucose, take medication consistently, seek care, and follow nutritional guidance \u0026ndash; challenges well documented in LMIC settings.\u003csup\u003e16\u003c/sup\u003e\u003csup\u003e,14,15,16,17,\u003c/sup\u003e\u003csup\u003e27\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eThis study extends existing evidence by capturing PLWD and HCWs experiences on bundled supplies and their potential to reduce those barriers.\u003c/p\u003e\n\u003cp\u003eFree diabetes treatments and medications were limited in all four countries, consistent with patterns across LMICs.11\u003csup\u003e,18,19,20,21,22,23,24\u0026nbsp;\u003c/sup\u003eParticipants commonly visited multiple facilities due to stockouts or paidhigher private-sector prices. Even when supplies were available, transportation costs, time away from work, and physical strain created additional burdens.\u003csup\u003e25,26\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eFew studies have examined bundling diabetes medications and supplies. The codesigned workshops responded directly to access and affordability challenges, producing a bundled solution that consolidates essential items, reduces costs through bulk purchasing, and eliminates the need to visit multiple outlets. Participants viewed the CarePak as an affordable, convenient option for obtaining consumables.\u003c/p\u003e\n\u003cp\u003eDiabetes self-management is influenced by personal, social, and health system factors and benefits from comprehensive education. \u003csup\u003e27,28\u003c/sup\u003e Participants expressed interest in practical guidance on nutrition and blood glucose control. These needs Informed the development of the CarePak booklet, though further HCW training is needed to support comprehensive nutritional counseling and clinical follow-up.\u003c/p\u003e\n\u003cp\u003eHCD has been widely applied to NCD interventions in countries such as Kenya, a cardiovascular disease program in HIV clinics, and digital health initiatives in LMICs, among other applications.\u003csup\u003e29,30,31\u003c/sup\u003e PATH has a strong history of using HCD to develop sustainable, user-friendly solutions. In this study, design activities drew on lived experiences and retail data to inform kit content, ensuring that the prototype CarePak reflected both user priorities and market realities.\u003c/p\u003e\n\u003cp\u003eThe retail outlet survey revealed substantial gaps in the availability and affordability of essential medicines and technologies, falling short of WHO targets. The retail survey\u0026rsquo;s quantitative findings, when analyzed alongside the qualitative results, underscore a systemic misalignment between supply chain functionality and patient realities: even where supplies exist, they remain financially or geographically out of reach.\u003c/p\u003e\n\u003cp\u003eStockouts of glucometers, test strips, lancets, and sharps containers, as well as high and variable prices, underscored the misalignment between supply chain performance and patient needs. Inconsistencies in insulin and syringe availability likely reflect procurement inefficiencies, weak regulation, and limited market competition. Centralized procurement, pooled purchasing, and local or regional production may help stabilize pricing. The high recurring cost of test strips remains a major barrier; subsidies or donor-supported distribution could improve access.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study adds to the limited literature on diabetes self-management in sub-Saharan Africa and reinforces the substantial financial and logistical burdens faced by PLWD in Mali, Mozambique, Tanzania, and Uganda.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003csup\u003e11\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e15\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e12\u003c/sup\u003e\u003csup\u003e,32,33,34,35\u0026nbsp;\u003c/sup\u003eFindings underscore the need for interventions at both individual and societal levels \u0026ndash; such as expanded HCW training improved price regulation; increased availability of affordable supplies; and strengthened support for self-monitoring and lifestyle management.\u003c/p\u003e\n\u003cp\u003eThe study also informed the development of a bundled kit to support safe insulin administration, with strong participant interest in such a solution. Further research should assess\u0026nbsp;the acceptability, usability, and health impacts of the CarePak prototypes and explore complementary approaches, including\u0026nbsp;enhanced diabetes education, peer support, and strategies to address food insecurity and the affordability of healthy foods.\u003c/p\u003e\n\u003cp\u003eThe growing diabetes burden in sub-Saharan Africa requires increased attention, resources, and innovation in clinical practice, social support, and technology. Alongside broader health system strengthening, interpersonal and community-level interventions remain essential to support lifelong diabetes self-management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed purposive sampling, which gave country teams flexibility in selecting eligible participants for interviews; however, the sample may not be representative of the broader population, limiting the generalizability of the results to other settings. The use of interviews in this study, while providing rich insights, is subject to social desirability bias, where participants may have responded in ways they believed were more socially acceptable rather than reflecting their true beliefs or behaviors. Further, data collection relied on a voluntary survey of retail outlet managers, which is susceptible to non-response bias Verbatim quotes were less extensive in Mali and Uganda due to shorter responses and the use of different data capture tools, such as Miro boards, instead of audio recordings.\u0026nbsp;\u003c/p\u003e"},{"header":"List of abbreviations","content":"\u003cp\u003e\u003cstrong\u003eADDO\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003eaccredited drug dispensing outlet\u003c/p\u003e\n\u003cp\u003eFGD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;focus group discussion\u003c/p\u003e\n\u003cp\u003eHCD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;human centered design\u003c/p\u003e\n\u003cp\u003eHCW\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;health care worker\u003c/p\u003e\n\u003cp\u003eIDI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;in-depth interview\u003c/p\u003e\n\u003cp\u003eIRB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;institutional review board\u003c/p\u003e\n\u003cp\u003eLMIC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;low- and middle-income country\u003c/p\u003e\n\u003cp\u003eMOH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;ministry of health\u003c/p\u003e\n\u003cp\u003ePLWD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;people living with diabetes\u003c/p\u003e\n\u003cp\u003eT1D\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;type 1 diabetes\u003c/p\u003e\n\u003cp\u003eT2D type \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; type 2 diabetes\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate.\u0026nbsp;\u003c/strong\u003eThe study was approved by the WIRB-Copernicus Group (WCG IRB) in the United States (June 8, 2022, research registration number 1334159); the Uganda National Council for Science and Technology (UNCST) (October 11, 2022, research registration number HS2418ES); the Mildmay Uganda Research Ethics Committee (MUREC) (August 29, 2022, research registration number MUREC-2022-133); the Tanzania National Institute for Medical Research (NIMR) (September 2, 2022, research registration number NIMR/HQ/R.8a/Vol/IX/4100); the Mozambique Comité National da Bioética para a Saúde (CNBS) (December 15, 2022, research registration number 861/CNBS/22); and the Mali Comité National d’Éthique pour la Santé et la Science de la Vie (CNESS) (May 8, 2023, research registration number 2023-091/MSDS-CNESS).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication.\u0026nbsp;\u003c/strong\u003eNot applicable (deidentified data only).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials.\u003c/strong\u003e The question guides used and datasets analyzed during this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests.\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding.\u0026nbsp;\u003c/strong\u003eThe study in Mali, Mozambique, and Tanzania was conducted by PATH with support from The Leona M. and Harry B. Helmsley Charitable Trust. The study in Uganda was supported by Sanofi. The funders had no role in the study’s conceptualization, design, data collection, analysis, decision to publish, or manuscript preparation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions.\u0026nbsp;\u003c/strong\u003eSW: project administration, supervision, formal qualitative analysis, writing (original draft, review, and editing). LR: writing (original draft), formal qualitative analysis. GA, GR, AM, GS, and BM: investigation. LM: project administration, writing (review and editing). AP: formal analysis (retail outlet survey). HM: funding acquisition, writing (review and editing). All contributing authors reviewed and approved the final version of the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments.\u0026nbsp;\u003c/strong\u003eThe team extends gratitude to collaborators from each country’s ministry of health, including district health officers and chief administrative officers in Uganda, as well as the President’s Office of Regional and Local Government (PORALG) in Tanzania. In Mozambique, the nonprofit Mozambique Diabetes Association (AMODIA) was instrumental in facilitating interviews with PLWD and HCWs, as were the Tanzania Diabetes Association (TDA) and the Uganda Diabetes Association (UDA). Gratitude is extended to PATH countries and global staff who support implementation, including Amy Heyden, Melanie Picolo, Betty Mirembe, Aminatou Sar, and Kevin Masibo.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eThe top 10 causes of death. Geneva: World Health Organization; 2020. https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death\u003c/li\u003e\n\u003cli\u003eGBD 2021 Diabetes Collaborators. Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021. Lancet, 2023. https://doi.org/10.1016/S0140-6736(23)01301-6\u003c/li\u003e\n\u003cli\u003eFlood D, et al. The state of diabetes treatment coverage in 55 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data in 680 102 adults. Lancet Healthy Longevity. 2021 Jun;2(6):e340-e351. doi: 10.1016/s2666-7568(21)00089-1.\u003c/li\u003e\n\u003cli\u003eStephani V, Opoku D, Beran D. Self-management of diabetes in sub-Saharan africa: A systematic review. BMC Public Health. 2018;18(1). doi:10.1186/s12889-018-6050-0\u003c/li\u003e\n\u003cli\u003eSong Y., Beltran Puerta J., Medina-Aedo M., et al. Self-Management Interventions for Adults Living with Type II Diabetes to Improve Patient-Important Outcomes: An Evidence Map. Healthcare, 11(24), 3156. 2023. https://doi.org/10.3390/healthcare11243156\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. https://www.who.int/news-room/feature-stories/detail/first-ever-global-coverage-targets-for-diabetes-adopted-at-the-75-th-world-health-assembly (Accessed June 27, 2025)\u003c/li\u003e\n\u003cli\u003eDiabetes Supplies: Are they there when needed? Seattle: PATH; 2015. https://media.path.org/documents/NCD_nes_exec_summary_CxMJvC8.pdf\u003c/li\u003e\n\u003cli\u003eAlijanzadeh, M., Hashemipour, S., Attaran, F. et al. Availability and affordability of diabetes healthcare services associated with the frequency of diabetes-related complications. BMC Health Serv Res 24, 1586 (2024). https://doi.org/10.1186/s12913-024-12065-x\u003c/li\u003e\n\u003cli\u003eSeuring T, Archangelidi O, Suhrcke M. The Economic Costs of Type 2 Diabetes: A Global Systematic Review. Pharmacoeconomics. 2015 Aug;33(8):811-31. doi: 10.1007/s40273-015-0268-9.\u003c/li\u003e\n\u003cli\u003eAfroz A, et al. Cost-of-illness of type 2 diabetes mellitus in low and lower-middle income countries: a systematic review. BMC Health Serv Res. 2018 Dec 17;18(1):972. doi: 10.1186/s12913-018-3772-8.\u003c/li\u003e\n\u003cli\u003eDhakal K. NVivo. Journal of the Medical Library Association. 2022;110(2). doi:10.5195/jmla.2022.1271\u003c/li\u003e\n\u003cli\u003eStephani V, Opoku D, Beran D. Self-management of diabetes in sub-Saharan africa: A systematic review. BMC Public Health. 2018;18(1). doi:10.1186/s12889-018-6050-0\u003c/li\u003e\n\u003cli\u003eSong Y., Beltran Puerta J., Medina-Aedo M., et al. Self-Management Interventions for Adults Living with Type II Diabetes to Improve Patient-Important Outcomes: An Evidence Map. Healthcare, 11(24), 3156. 2023. https://doi.org/10.3390/healthcare11243156\u003c/li\u003e\n\u003cli\u003eBeran D, Yudkin JS. Looking beyond the issue of access to insulin: What is needed for proper diabetes care in resource poor settings. Diabetes Research and Clinical Practice. 2010;88(3):217\u0026ndash;21. doi:10.1016/j.diabres.2010.03.029\u003c/li\u003e\n\u003cli\u003eWhittemore R, Vilar-Compte M, De La Cerda S, Marron D, Conover R, Delvy R, et al. Challenges to diabetes self-management for adults with type 2 diabetes in low-resource settings in Mexico City: A qualitative descriptive study. International Journal for Equity in Health. 2019;18(1). doi:10.1186/s12939-019-1035-x\u003c/li\u003e\n\u003cli\u003eYasmin F, Ali L, Banu B, Rasul FB, Sauerborn R, Souares A. Understanding patients\u0026rsquo; experience living with diabetes type 2 and effective disease management: A qualitative study following a mobile health intervention in Bangladesh. BMC Health Services Research. 2020;20(1). doi:10.1186/s12913-019-4811-9\u003c/li\u003e\n\u003cli\u003eRobbiati C, Armando A, da Concei\u0026ccedil;\u0026atilde;o N, Putoto G, Cavallin F. Association between diabetes and food insecurity in an urban setting in Angola: A case\u0026ndash;control study. Scientific Reports. 2022;12(1). doi:10.1038/s41598-022-04888-7\u003c/li\u003e\n\u003cli\u003eAdler AJ, Trujillo C, Schwartz L, Drown L, Pierre J, Noble C, et al. Experience of living with type 1 diabetes in a low-income country: A qualitative study from Liberia. BMJ Open. 2021;11(10). doi:10.1136/bmjopen-2021-049738\u003c/li\u003e\n\u003cli\u003eAtun R, Davies JI, Gale EA, B\u0026auml;rnighausen T, Beran D, Kengne AP, et al. Diabetes in sub-Saharan africa: From clinical care to health policy. The Lancet Diabetes \u0026amp;amp; Endocrinology. 2017;5(8):622\u0026ndash;67. doi:10.1016/s2213-8587(17)30181-x\u003c/li\u003e\n\u003cli\u003eBeran D, Silva Matos C, Yudkin JS. The diabetes UK Mozambique Twinning Programme. results of improvements in diabetes care in Mozambique: A reassessment 6 years later using the Rapid Assessment Protocol for insulin access. Diabetic Medicine. 2010;27(8):855\u0026ndash;61. doi:10.1111/j.1464-5491.2010.03053.x\u003c/li\u003e\n\u003cli\u003eFlood D, Seiglie JA, Dunn M, Tschida S, Theilmann M, Marcus ME, et al. The state of diabetes treatment coverage in 55 low-income and middle-income countries: A cross-sectional study of nationally representative, individual-level data in 680102 adults. The Lancet Healthy Longevity. 2021;2(6). doi:10.1016/s2666-7568(21)00089-1\u003c/li\u003e\n\u003cli\u003eTusubira AK, Akiteng AR, Nakirya BD, Nalwoga R, Ssinabulya I, Nalwadda CK, et al. Accessing medicines for noncommunicable diseases: Patients and Health Care Workers\u0026rsquo; experiences at public and private health facilities in Uganda. PLOS ONE. 2020;15(7). doi:10.1371/journal.pone.0235696\u003c/li\u003e\n\u003cli\u003ePATH. Journey of the Pill: Findings of the NCD Commodity Supply Chain Assessment in Kenya. Seattle: PATH; 2020.\u003c/li\u003e\n\u003cli\u003eJustin-Temu M, Nondo RSO, Wiedenmayer K, Ramaiya KL, Teuscher A. Anti-diabetic drugs in the private and public sector in Dar es Salaam, Tanzania. East African Medical Journal. 2010;86(3). doi:10.4314/eamj.v86i3.54962\u003c/li\u003e\n\u003cli\u003eCastillo-Laborde C, Hirmas-Adauy M, Matute I, Jasmen A, Urrejola O, Molina X, Awad C, Frey-Moreno C, Pumarino-Lira S, Descalzi-Rojas F, Ruiz TJ, Plass B. Barriers and Facilitators in Access to Diabetes, Hypertension, and Dyslipidemia Medicines: A Scoping Review. Public Health Rev. 2022 Sep 2;43:1604796. doi: 10.3389/phrs.2022.1604796. PMID: 36120091; PMCID: PMC9479461.\u003c/li\u003e\n\u003cli\u003eWudil AH, Usman M, Rosak-Szyrocka J, Pilař L, Boye M. Reversing years for Global Food Security: A review of the food security situation in sub-Saharan africa (SSA). International Journal of Environmental Research and Public Health. 2022;19(22):14836. doi:10.3390/ijerph192214836\u003c/li\u003e\n\u003cli\u003eJuarez LD, Presley CA, Howell CR, Agne AA, Cherrington AL. The Mediating Role of Self-Efficacy in the Association Between Diabetes Education and Support and Self-Care Management. Health Education \u0026amp; Behavior. 2022;49(4):689-696. doi:10.1177/10901981211008819\u003c/li\u003e\n\u003cli\u003eMasupe T, Onagbiye S, Puoane T, Pilvikki A, Alvesson HM, Delobelle P. Diabetes self-management: A qualitative study on challenges and solutions from the perspective of South African patients and health care providers. Global Health Action. 2022;15(1). doi:10.1080/16549716.2022.2090098\u003c/li\u003e\n\u003cli\u003eLeung CL, Naert M, Andama B, et al. Human-centered design as a guide to intervention planning for noncommunicable diseases: the BIGPIC study from Western Kenya. BMC Health Serv Res. 2020 May 12;20(1):415. doi: 10.1186/s12913-020-05199-1. Erratum in: BMC Health Serv Res. 2020 Aug 12;20(1):738. doi: 10.1186/s12913-020-05345-9. PMID: 32398131; PMCID: PMC7218487.\u003c/li\u003e\n\u003cli\u003eAifah A, Okeke NL, Rentrope CR, et al. Use of a human-centered design approach to adapt a nurse-led cardiovascular disease prevention intervention in HIV clinics. Prog Cardiovasc Dis. 2020 Mar-Apr;63(2):92-100. doi: 10.1016/j.pcad.2020.02.013. Epub 2020 Feb 21. PMID: 32092444; PMCID: PMC7237285.\u003c/li\u003e\n\u003cli\u003eBlynn E, Harris E, Wendland M, et al. Integrating Human-Centered Design to Advance Global Health: Lessons From 3 Programs. Glob Health Sci Pract. 2021 Nov 29;9(Suppl 2):S261-S273. doi: 10.9745/GHSP-D-21-00279. PMID: 34845049; PMCID: PMC8628497.\u003c/li\u003e\n\u003cli\u003eMayega RW, Etajak S, Rutebemberwa E, Tomson G, Kiguli J. \u0026lsquo;Change means sacrificing a good life\u0026rsquo;: Perceptions about severity of type 2 diabetes and preventive lifestyles among people afflicted or at high risk of type 2 diabetes in Iganga Uganda. BMC Public Health. 2014;14(1). doi:10.1186/1471-2458-14-864\u003c/li\u003e\n\u003cli\u003eHjelm K, Nambozi G. Beliefs about health and illness: A comparison between Ugandan men and women living with diabetes mellitus. International Nursing Review. 2008;55(4):434\u0026ndash;41. doi:10.1111/j.1466-7657.2008.00665.x\u003c/li\u003e\n\u003cli\u003eBaumann LC, Frederick N, Betty N, Jospehine E, Agatha N. A demonstration of peer support for Ugandan adults with type 2 diabetes. International Journal of Behavioral Medicine. 2014;22(3):374\u0026ndash;83. doi:10.1007/s12529-014-9412-8\u003c/li\u003e\n\u003cli\u003eNielsen J, Bahendeka SK, Bygbjerg IC, Meyrowitsch DW, Whyte SR. Accessing diabetes care in rural Uganda: Economic and Social Resources. Global Public Health. 2016;12(7):892\u0026ndash;908. doi:10.1080/17441692.2016.1172100\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Accredited Drug Dispensing Outlets (ADDOs) are qualified drug retail outlets established through public‒private partnerships with the government in Tanzania to maintain standards while increasing access to pharmaceutical sales points.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"diabetes self-care, supplies, access, affordability, Diabetes CarePak, human-centered design","lastPublishedDoi":"10.21203/rs.3.rs-7707279/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7707279/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eConsistent access to high-quality medicines and affordable health products remains a persistent challenge for people living with diabetes (PLWD) in low- and middle-income countries. PLWD lack access to essential commodities to prevent diabetes-related complications, face catastrophic out-of-pocket costs, are often unable to monitor their blood sugar, may ration medication and reuse syringes, and have limited access to diabetes education. This publication presents findings from a mixed-methods landscape assessment and retail outlet survey conducted between 2022 and 2024 in Mali, Mozambique, Tanzania, and Uganda to understand diabetes self-care and management practices, barriers to and facilitators of care, retail costs, and access to medicines and supplies. The results of the study informed a human-centered design process to develop a prototype diabetes self-care kit called the “Diabetes CarePak.”\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe study team conducted semi-structured in-depth interviews and focus groups with PLWD, health care workers, and stakeholders in Mali, Mozambique, Tanzania, and Uganda to assess key issues related to diabetes self-care and disease management. The study included a retail outlet survey of 150 public and private outlets across the four countries to examine the pricing and stock levels of essential supplies. Subsequently, human-centered design approaches were used in cocreation workshops with end users in each country to develop a prototype kit of diabetes management supplies and educational and health care worker training materials.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eStudy findings underscore significant barriers to access to and affordability of essential diabetes care supplies, including the unavailability of blood glucose testing even at local health clinics, low ownership of glucometers, difficulty finding brand-matched test strips, and inconsistent stock and high costs of diabetes supplies in pharmacies and retail outlets. Financial hardship and food insecurity impeded individuals’ ability to monitor glucose, adhere to medication, seek care at health facilities, and follow nutritional guidance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThis study documented key diabetes self-care challenges, highlighted the advantages and desirability of a bundled solution, and employed a human-centered design to develop the CarePak prototype.\u003c/p\u003e","manuscriptTitle":"Supplying solutions: A mixed-methods study on experiences with access to diabetes care supplies in four African countries to inform the development of a bundled solution for improved self-care and clinical management","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-05 11:33:42","doi":"10.21203/rs.3.rs-7707279/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-07T09:53:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"92466849374159839497983918612455502565","date":"2026-02-28T14:11:38+00:00","index":"hide","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-03T09:16:29+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"121226114985505064566712120866126639978","date":"2025-12-04T12:29:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-03T13:35:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-22T22:27:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-11-22T22:24:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b2ffaa8f-e4c3-4039-9b3d-7cce6af88302","owner":[],"postedDate":"December 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-05T11:33:42+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-05 11:33:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7707279","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7707279","identity":"rs-7707279","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}