Evaluating the implementation of Group Empowerment and Training (GREAT) for diabetes in South Africa: Convergent mixed methods

Abstract Background Diabetes is a leading contributor to the burden of disease in South Africa. The new National Strategic Plan for non-communicable diseases aims to achieve control in 50% of patients. Currently, in the Western Cape, only 25% are controlled and a lack of patient education and counselling is a key factor. Group empowerment and training (GREAT) for diabetes is a feasible and cost-effective intervention in our setting. This study aimed to evaluate the scale-up and implementation of GREAT for diabetes in primary care across five provinces. Methods A convergent mixed methods study evaluated a range of implementation outcomes. Descriptive exploratory individual semi-structured interviews were conducted with 31 key stakeholders from national policymakers to primary care providers. Five focus group interviews were held with patients. Qualitative data explored the acceptability, appropriateness, adoption, feasibility, fidelity and sustainability of GREAT. Quantitative data was collected on the training course, observations of GREAT, coverage and cost. Results Five out of nine provinces implemented GREAT, despite the challenges of the COVID-19 pandemic. The findings informed the design of a programme theory using a health system framework. Health system structures required support from National and Provincial level policymakers, identification of high prevalence districts and allocation of funds. Health system inputs required attention to physical space for groups, sufficient staff numbers to facilitate groups, availability of the resource materials and monitoring within the health information system. Key activities included adaptation to the model of care (selection of facilities, patients, adjustment of patient flow and appointment systems and leadership of local managers across the whole clinical team), training of facilitators and trainers and inclusion in systems for quality improvement. Identified outputs related to the availability of GREAT and improved quality of care (viz person-centredness, self-management, social support and health literacy). Expected outcomes related to improved coverage, diabetic control and patient satisfaction. Conclusions Key lessons were learnt on how to implement GREAT for diabetes in a middle-income country primary care system. The programme theory will guide further scale-up in each province and scale-out to provinces that have not yet implemented.