Evaluating the implementation of group empowerment for people with type 2 diabetes at Grassy Park Community Day Centre, Cape Town: A convergent mixed-methods study

Abstract

Background: Diabetes is a major contributor to the burden of disease in South Africa, but glycaemic control is poor. Group empowerment and training (GREAT) for people with type 2 diabetes is a cost-effective intervention in our setting. The aim was to evaluate the implementation of GREAT for diabetes at a primary care facility in Cape Town.
Methods: A convergent mixed-method study evaluated implementation outcomes over 6 months. A programme theory model was used to prospectively plan implementation. Semi-structured individual interviews were held with healthcare workers, focus group interviews with patients and sessions were observed to evaluate adoption, feasibility, fidelity and sustainability. Quantitative data evaluated reach, cost and aspects of fidelity. Qualitative data analysis used ATLAS.ti and the framework method. Data were analysed deductively according to the pre-determined implementation outcomes.
Results: Key stakeholders agreed that GREAT was acceptable and appropriate and encouraged adoption. Initial implementation reached 35 patients in four groups and 65% of those invited attended. Only 29% attended all four sessions. Fidelity of the intervention to the training manual was good. Several contextual factors influenced the feasibility of implementation (e.g. support of management, space for group sessions, integration with appointment system, effect on number of walk-in patients, streamlined referral system). Incremental operational costs were trivial (R30/month), while opportunity costs were higher (R26 252/month). Sustainability will be related to ongoing managerial and staff buy-in and adjustment of the implementation strategies to overcome some of the barriers.
Conclusion: The study identified 30 determinants of successful implementation outcomes.
Contribution: Can guide future implementation in similar contexts as GREAT for diabetes is scaled-up in Cape Town and scaled-out to other provinces in South Africa.