Evaluating the Implementation of the GREAT4Diabetes WhatsApp Chatbot to Educate People With Type 2 Diabetes During the COVID-19 Pandemic: Convergent Mixed Methods Study

Abstract

Background In South Africa, diabetes is a leading cause of morbidity and mortality, which was exacerbated during the COVID-19 pandemic. Most education and counseling activities were stopped during the lockdown, and the GREAT4Diabetes WhatsApp Chatbot was innovated to fill this gap. Objective This study aimed to evaluate the implementation of the chatbot in Cape Town, South Africa, between May and October 2021. Methods Convergent mixed methods were used to evaluate the implementation outcomes: acceptability, adoption, appropriateness, feasibility, fidelity, cost, coverage, effects, and sustainability. Quantitative data were derived from the chatbot and analyzed using the SPSS. Qualitative data were collected from key informants and analyzed using the framework method assisted by Atlas-ti. The chatbot provided users with 16 voice messages and graphics in English, Afrikaans, or Xhosa. Messages focused on COVID-19 infection and self-management of type 2 diabetes. Results The chatbot was adopted by the Metro Health Services to assist people with diabetes who had restricted health care during the lockdown and were at a higher risk of hospitalization and death from COVID-19 infection. The chatbot was disseminated via health care workers in primary care facilities and local nonprofit organizations and via local media and television. Two technical glitches interrupted the dissemination but did not substantially affect user behavior. Minor changes were made to the chatbot to improve its utility. Many patients had access to smartphones and were able to use the chatbot via WhatsApp. Overall, 8158 people connected with the chatbot and 4577 (56.1%) proceeded to listen to the messages, with 12.56% (575/4577) of them listening to all 16 messages, mostly within 32 days. The incremental setup costs were ZAR 255,000 (US $16,876) and operational costs over 6 months were ZAR 462,473 (US $30,607). More than 90% of the users who listened to each message found them useful. Of the 533 who completed the whole program, 351 (71.1%) said they changed their self-management a lot and 87.6% (369/421) were more confident. Most users changed their lifestyles in terms of diet (315/414, 76.1%) and physical activity (222/414, 53.6%). Health care workers also saw benefits to patients and recommended that the service continues. Sustainability of the chatbot will depend on the future policy of the provincial Department of Health toward mobile health and the willingness to contract with Aviro Health. There is the potential to go to scale and include other languages and chronic conditions. Conclusions The chatbot shows great potential to complement traditional health care approaches for people with diabetes and assist with more comprehensive patient education. Further research is needed to fully explore the patient’s experience of the chatbot and evaluate its effectiveness in our context.

Digital Health Solutions for Community-Based Control of Diabetes During COVID-19 Pandemic: A Scoping Review of Implementation Outcomes

“…Digital health solutions, such as the GREAT4Diabetes WhatsApp Chat bot, had a primary focus on delivering messages that were essential for people with diabetes. 17 , 19 …”

“…The absence of formal guidelines and a secured platform for data transfer has created this challenge. 19 …”

Comprehensive patient education and counselling for non-communicable diseases in primary care, Western Cape

“…A GREAT for diabetes WhatsApp Chatbot took the content of the education and provided it as 16 brief audio messages to people with diabetes. 29 This innovation has the potential to reduce workload in the facility as patients can listen to the whole programme in their own time. However, there is no real opportunity for interaction or learning from a group.…”

Factors influencing insulin initiation in primary care facilities in Cape Town, South Africa

“…In Cape Town, a WhatsApp Chatbot has been shown useful in diabetes education. 29 In Tshwane, a nurse-driven application has supported people as they start insulin with some success. 30 Guidelines should specify the timing and broad content of counselling for patients regarding the use of insulin.…”