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Article ; Online: Access to Hemoglobin A1c in Rural Africa: A Difficult Reality with Severe Consequences.

Park, Paul H / Pastakia, Sonak D

2018 Volume 2018, Page(s) 6093595

Abstract: Sub-Saharan Africa (SSA) continues to have the highest diabetes-related mortality rate in the world. While there exists a multitude of health system barriers driving poor diabetes control, rural facilities particularly in SSA lack access to proper ... ...

Abstract	Sub-Saharan Africa (SSA) continues to have the highest diabetes-related mortality rate in the world. While there exists a multitude of health system barriers driving poor diabetes control, rural facilities particularly in SSA lack access to proper monitoring of glucose and other key biologic tests. At best, most of these diabetes patients receive random blood sugar readings only on the day of their clinic visit. This approach has very limited clinical value in determining dosage adjustments for narrow therapeutic index medications such as insulin. Furthermore, access to other blood tests and physical exam tools for detecting early signs of diabetes complications is limited. We propose that routine access to hemoglobin A1c (HbA1c) testing would not only allow for close monitoring of diabetes control but also provide critical data informing the population level risk for diabetes complications. However, implementing HbA1c testing does have its own barriers at rural facilities, including high costs, refrigeration requirements, and perceived discordance between HbA1c values and mean blood glucose levels for SSA patients. Fortunately, several pilots in rural SSA have illustrated feasibility of HbA1c testing. Further political will, price reduction, and context-specific research are needed. Increasing access to HbA1c testing is a critical step to combat the high diabetes-related mortality rates in rural SSA.
MeSH term(s)	Africa ; Diabetes Mellitus, Type 1/blood ; Glycated Hemoglobin A/analysis ; Health Services Accessibility ; Hematologic Tests ; Humans ; Rural Population
Chemical Substances	Glycated Hemoglobin A
Language	English
Publishing date	2018-02-26
Publishing country	England
Document type	Journal Article ; Review
ZDB-ID	2711897-6
ISSN	2314-6753 ; 2314-6745
ISSN (online)	2314-6753
ISSN	2314-6745
DOI	10.1155/2018/6093595
Database	MEDical Literature Analysis and Retrieval System OnLINE

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Article ; Online: Appropriateness and acceptability of continuous glucose monitoring in people with type 1 diabetes at rural first-level hospitals in Malawi: a qualitative study.

Thapa, Ada / Chibvunde, Stellar / Schwartz, Leah / Trujillo, Celina / Ferrari, Gina / Drown, Laura / Gomber, Apoorva / Park, Paul H / Matanje, Beatrice / Msekandiana, Amos / Kachimanga, Chiyembekezo / Bukhman, Gene / Ruderman, Todd / Adler, Alma J

BMJ open

2024 Volume 14, Issue 5, Page(s) e075559

Abstract: Objectives: The purpose of this qualitative study is to describe the acceptability and appropriateness of continuous glucose monitoring (CGM) in people living with type 1 diabetes (PLWT1D) at first-level (district) hospitals in Malawi.: Design: We ... ...

Abstract	Objectives: The purpose of this qualitative study is to describe the acceptability and appropriateness of continuous glucose monitoring (CGM) in people living with type 1 diabetes (PLWT1D) at first-level (district) hospitals in Malawi. Design: We conducted semistructured qualitative interviews among PLWT1D and healthcare providers participating in the study. Standardised interview guides elicited perspectives on the appropriateness and acceptability of CGM use for PLWT1D and their providers, and provider perspectives on the effectiveness of CGM use in Malawi. Data were coded using Dedoose software and analysed using a thematic approach. Setting: First-level hospitals in Neno district, Malawi. Participants: Participants were part of a randomised controlled trial focused on CGM at first-level hospitals in Neno district, Malawi. Pretrial and post-trial interviews were conducted for participants in the CGM and usual care arms, and one set of interviews was conducted with providers. Results: Eleven PLWT1D recruited for the CGM randomised controlled trial and five healthcare providers who provided care to participants with T1D were included. Nine PLWT1D were interviewed twice, two were interviewed once. Of the 11 participants with T1D, six were from the CGM arm and five were in usual care arm. Key themes emerged regarding the appropriateness and effectiveness of CGM use in lower resource setting. The four main themes were (a) patient provider relationship, (b) stigma and psychosocial support, (c) device usage and (d) clinical management. Conclusions: Participants and healthcare providers reported that CGM use was appropriate and acceptable in the study setting, although the need to support it with health education sessions was highlighted. This research supports the use of CGM as a component of personalised diabetes treatment for PLWT1D in resource constraint settings. Trial registration number: PACTR202102832069874; Post-results.
MeSH term(s)	Humans ; Malawi ; Diabetes Mellitus, Type 1/blood ; Diabetes Mellitus, Type 1/therapy ; Diabetes Mellitus, Type 1/psychology ; Male ; Qualitative Research ; Female ; Adult ; Blood Glucose Self-Monitoring ; Patient Acceptance of Health Care ; Middle Aged ; Blood Glucose/analysis ; Interviews as Topic ; Hospitals, Rural ; Hospitals, District ; Continuous Glucose Monitoring
Chemical Substances	Blood Glucose
Language	English
Publishing date	2024-05-06
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't ; Randomized Controlled Trial
ZDB-ID	2599832-8
ISSN	2044-6055 ; 2044-6055
ISSN (online)	2044-6055
ISSN	2044-6055
DOI	10.1136/bmjopen-2023-075559
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Article ; Online: Chronic care service delivery models for people living with type 1 diabetes in low- and lower-middle income countries: a scoping review protocol.

Noble, Christopher / Adler, Alma / Park, Paul H / Bavuma, Charlotte / Worster, Devin / Bukhman, Gene

JBI evidence synthesis

2020 Volume 18, Issue 11, Page(s) 2363–2372

Abstract: Objective: The objective of this scoping review is to map the published literature that describes the distribution and organization of chronic care service delivery models for people living with type 1 diabetes (PLWT1D) in low- and lower-middle-income ... ...

Abstract	Objective: The objective of this scoping review is to map the published literature that describes the distribution and organization of chronic care service delivery models for people living with type 1 diabetes (PLWT1D) in low- and lower-middle-income countries (LLMICs). Introduction: Type 1 diabetes is an autoimmune condition commonly diagnosed in childhood and early adolescence; it cannot be prevented and is deadly without daily insulin injections. Among PLWT1D, the islet cells in the pancreas produce insufficient amounts of the glucose-regulating hormone, insulin, resulting in the need for chronic insulin replacement therapy. Epidemiological information regarding type 1 diabetes (T1D) is limited in LLMICs. Improving survival for PLWT1D in LLMICs requires early diagnosis and greater access to high quality chronic care service delivery models for T1D. The identification and reporting of service delivery model typologies for PLWT1D will allow for more specific research questions regarding individual typologies in subsequent systematic reviews. Inclusion criteria: The review will consider all types of literature on the organization and distribution of chronic care services for the management of PLWT1D provided out of facilities in LLMICs, published from 2000 to the present. Methods: The JBI methodology for conducting scoping reviews will be employed. The search will be implemented across PubMed, Embase, and Web of Science. Full texts of the publications selected will be reviewed and data will be extracted through a charting table. The findings will be charted to summarize the results.
MeSH term(s)	Adolescent ; Delivery of Health Care ; Developing Countries ; Diabetes Mellitus, Type 1/drug therapy ; Humans ; Income ; Long-Term Care ; Review Literature as Topic
Language	English
Publishing date	2020-05-28
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ISSN	2689-8381
ISSN (online)	2689-8381
DOI	10.11124/JBISRIR-D-19-00086
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Article ; Online: Feasibility of continuous glucose monitoring in patients with type 1 diabetes at two district hospitals in Neno, Malawi: a randomised controlled trial.

BMJ open

2024 Volume 14, Issue 5, Page(s) e075554

Abstract: Objectives: To assess the feasibility and change in clinical outcomes associated with continuous glucose monitoring (CGM) use among a rural population in Malawi living with type 1 diabetes.: Design: A 2:1 open randomised controlled feasibility trial.! ...

Abstract	Objectives: To assess the feasibility and change in clinical outcomes associated with continuous glucose monitoring (CGM) use among a rural population in Malawi living with type 1 diabetes. Design: A 2:1 open randomised controlled feasibility trial. Setting: Two Partners In Health-supported Ministry of Health-run first-level district hospitals in Neno, Malawi. Participants: 45 people living with type 1 diabetes (PLWT1D). Interventions: Participants were randomly assigned to Dexcom G6 CGM (n=30) use or usual care (UC) (n=15) consisting of Safe-Accu glucose monitors and strips. Both arms received diabetes education. Outcomes: Primary outcomes included fidelity, appropriateness and severe adverse events. Secondary outcomes included change in haemoglobin A1c (HbA1c), acceptability, time in range (CGM arm only) SD of HbA1c and quality of life. Results: Participants tolerated CGM well but were unable to change their own sensors which resulted in increased clinic visits in the CGM arm. Despite the hot climate, skin rashes were uncommon but cut-out tape overpatches were needed to secure the sensors in place. Participants in the CGM arm had greater numbers of dose adjustments and lifestyle change suggestions than those in the UC arm. Participants in the CGM arm wore their CGM on average 63.8% of the time. Participants in the UC arm brought logbooks to clinic 75% of the time. There were three hospitalisations all in the CGM arm, but none were related to the intervention. Conclusions: This is the first randomised controlled trial conducted on CGM in a rural region of a low-income country. CGM was feasible and appropriate among PLWT1D and providers, but inability of participants to change their own sensors is a challenge. Trial registration number: PACTR202102832069874.
MeSH term(s)	Humans ; Malawi ; Diabetes Mellitus, Type 1/blood ; Diabetes Mellitus, Type 1/drug therapy ; Female ; Male ; Feasibility Studies ; Blood Glucose Self-Monitoring/methods ; Adult ; Glycated Hemoglobin/analysis ; Hospitals, District ; Blood Glucose/analysis ; Middle Aged ; Quality of Life ; Rural Population ; Continuous Glucose Monitoring
Chemical Substances	Glycated Hemoglobin ; Blood Glucose
Language	English
Publishing date	2024-05-06
Publishing country	England
Document type	Journal Article ; Randomized Controlled Trial ; Research Support, Non-U.S. Gov't ; Multicenter Study
ZDB-ID	2599832-8
ISSN	2044-6055 ; 2044-6055
ISSN (online)	2044-6055
ISSN	2044-6055
DOI	10.1136/bmjopen-2023-075554
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Article ; Online: Protocol for a feasibility randomised control trial for continuous glucose monitoring in patients with type 1 diabetes at first-level hospitals in rural Malawi.

Adler, Alma J / Ruderman, Todd / Valeta, Francis / Drown, Laura / Trujillo, Celina / Ferrari, Gina / Msekandiana, Amos / Wroe, Emily / Kachimanga, Chiyembekezo / Bukhman, Gene / Park, Paul H

BMJ open

2022 Volume 12, Issue 2, Page(s) e052134

Abstract: Introduction: The majority of people living with type 1 diabetes (PLWT1D) struggle to access high-quality care in low-income countries (LICs), and lack access to technologies, including continuous glucose monitoring (CGM), that are considered standard ... ...

Abstract	Introduction: The majority of people living with type 1 diabetes (PLWT1D) struggle to access high-quality care in low-income countries (LICs), and lack access to technologies, including continuous glucose monitoring (CGM), that are considered standard of care in high resource settings. To our knowledge, there are no studies in the literature describing the feasibility or effectiveness of CGM at rural first-level hospitals in LICs. Methods and analysis: This is a 3-month, 2:1 open-randomised trial to assess the feasibility and clinical outcomes of introducing CGM to the entire population of 50 PLWT1D in two hospitals in rural Neno, Malawi. Participants in both arms will receive 2 days of training on diabetes management. One day of training will be the same for both arms, and one will be specific to the diabetes technology. Participants in the intervention arm will receive Dexcom G6 CGM devices with sensors and solar chargers, and patients in the control arm will receive Safe-Accu home glucose metres and logbooks. All patients will have their haemoglobin A1c (HbA1c) measured and take WHO Quality of Life assessments at study baseline and endline. We will conduct qualitative interviews with a selection of participants from both arms at the beginning and end of study and will interview providers at the end of the study. Our primary outcomes of interest are fidelity to protocols, appropriateness of technology, HbA1c and severe adverse events. Ethics and dissemination: This study is approved by National Health Sciences Research Committee of Malawi (IRB Number IR800003905) and the Mass General Brigham (IRB number 2019P003554). Findings will be disseminated to PLWT1D through health education sessions. We will disseminate any relevant findings to clinicians and leadership within our study catchment area and networks. We will publish our findings in an open-access peer-reviewed journal. Trial registration number: PACTR202102832069874.
MeSH term(s)	Blood Glucose ; Blood Glucose Self-Monitoring ; Diabetes Mellitus, Type 1/therapy ; Feasibility Studies ; Hospitals ; Humans ; Malawi ; Quality of Life ; Randomized Controlled Trials as Topic
Chemical Substances	Blood Glucose
Language	English
Publishing date	2022-02-23
Publishing country	England
Document type	Clinical Trial Protocol ; Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2599832-8
ISSN	2044-6055 ; 2044-6055
ISSN (online)	2044-6055
ISSN	2044-6055
DOI	10.1136/bmjopen-2021-052134
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Article ; Online: Evaluating implementation of Diabetes Self-Management Education in Maryland County, Liberia: protocol for a pilot prospective cohort study.

Trujillo, Celina / Ferrari, Gina / Ngoga, Gedeon / McLaughlin, Amy / Davies, Joe / Tucker, Anthony / Randolph, Cyrus / Cook, Rebecca / Park, Paul H / Bukhman, Gene / Adler, Alma J / Pierre, Jacquelin

BMJ open

2022 Volume 12, Issue 10, Page(s) e060592

Abstract: Introduction: Achieving glycaemic targets for people living with diabetes (PLWD) is challenging, especially in settings with limited resources. Programmes need to address gaps in knowledge, skills and self-management. Diabetes Self-Management Education ( ...

Abstract	Introduction: Achieving glycaemic targets for people living with diabetes (PLWD) is challenging, especially in settings with limited resources. Programmes need to address gaps in knowledge, skills and self-management. Diabetes Self-Management Education (DSME) is an evidence-based intervention to educate and empower PLWD to improve self-management activities. This protocol describes a pilot study assessing the feasibility, acceptability and effect on clinical outcomes of implementing DSME in clinics caring for people living with insulin-dependent diabetes in Liberia. Methods and analysis: Our protocol is a three-phased, mixed-methods, quasi-experimental prospective cohort study. Phase 1 focuses on (a) establishing a Patient Advisory Board and (b) training providers in DSME who provide care for PLWD. In phase 2, clinicians will implement DSME. In phase 3, we will train additional providers who interact with PLWD.We will assess whether this DSME programme can lead to increased provider knowledge of DSME, improvements in diabetes self-management behaviours, glycaemic control, diabetes knowledge and psychosocial well-being, and a reduction in severe adverse events. Primary outcomes of interest are implementation outcomes and change in frequency of self-management behaviours by patients. Secondary outcomes include change in haemoglobin A1c, psychosocial well-being, severe adverse events and change in provider knowledge of DSME. Ethics and dissemination: Ethical approval was obtained from the University of Liberia Institutional Review Board (IRB) and the Brigham and Women's Hospital IRB. Findings from the study will be shared with local and national clinical and programmatic stakeholders and published in an open-access, peer-reviewed journal.
MeSH term(s)	Diabetes Mellitus, Type 2/psychology ; Diabetes Mellitus, Type 2/therapy ; Female ; Glycated Hemoglobin A/analysis ; Humans ; Insulins ; Liberia ; Maryland ; Pilot Projects ; Prospective Studies ; Self Care/methods ; Self-Management/education
Chemical Substances	Glycated Hemoglobin A ; Insulins
Language	English
Publishing date	2022-10-17
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2599832-8
ISSN	2044-6055 ; 2044-6055
ISSN (online)	2044-6055
ISSN	2044-6055
DOI	10.1136/bmjopen-2021-060592
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Article ; Online: Feasibility and effectiveness of self-monitoring of blood glucose among insulin-dependent patients with type 2 diabetes: open randomized control trial in three rural districts in Rwanda.

Ng'ang'a, Loise / Ngoga, Gedeon / Dusabeyezu, Symaque / Hedt-Gauthier, Bethany L / Harerimana, Emmanuel / Niyonsenga, Simon Pierre / Bavuma, Charlotte M / Bukhman, Gene / Adler, Alma J / Kateera, Fredrick / Park, Paul H

BMC endocrine disorders

2022 Volume 22, Issue 1, Page(s) 244

Abstract: Background: The prevalence of type 2 diabetes in sub Saharan Africa (SSA) has been on the rise. Effective control of blood glucose is key towards reducing the risk of diabetes complications. Findings mainly from high-income countries have demonstrated ... ...

Abstract	Background: The prevalence of type 2 diabetes in sub Saharan Africa (SSA) has been on the rise. Effective control of blood glucose is key towards reducing the risk of diabetes complications. Findings mainly from high-income countries have demonstrated the effectiveness of self-monitoring of blood-glucose (SMBG) in controlling blood glucose levels. However, there are limited studies describing the implementation of SMBG in rural SSA. This study explores the feasibility and effectiveness of implementing SMBG among patients diagnosed with insulin-dependent type 2 diabetes in rural Rwanda. Methods: Participants were randomized into intervention (n = 42) and control (n = 38) groups. The intervention group received a glucose-meter, blood test-strips, log-book, waste management box and training on SMBG in addition to usual care. The control group continued with their usual care consisting of, routine monthly medical consultation and health education. The primary outcomes were adherence to the implementation of SMBG (testing schedule and recording data in the log-book) and change in hemoglobin A1c. Descriptive statistics and a paired t-test were used to analyze the primary outcomes. Results: In both the intervention and control arms, majority of the participants were female (59.5% vs 52.6%) and married (71.4% vs 73.7%). Most had at most a primary level education (83.3% vs. 89.4%) and were farmers (54.8% vs. 50.0%). Among those in the intervention group, 63.4% showed good adherence to implementing SMBG based on the number of tests recorded in the glucose meter. Only 20.3% demonstrated accurate recording of the glucose level tests in log-books. The mean difference of the HbA1C from baseline to six months post-intervention was significantly better among the intervention group -0.94% (95% CI -1.46, -0.41) compared to the control group 0.73% (95% CI -0.09, 1.54) p < 0.001. Conclusion: Our study showed that among patients with insulin-dependent type 2 diabetes residing in rural Rwanda, SMBG was feasible and demonstrated positive outcomes in improving blood glucose control. However, there is need for strategies to enhance accuracy in recording blood glucose test results in the log-book. Trial registration: The trial was registered retrospectively on the Pan African Clinical Trial Registry, on 17
MeSH term(s)	Blood Glucose ; Blood Glucose Self-Monitoring/methods ; Diabetes Mellitus, Type 1 ; Diabetes Mellitus, Type 2/epidemiology ; Diabetes Mellitus, Type 2/therapy ; Feasibility Studies ; Female ; Glucose ; Glycated Hemoglobin A/analysis ; Humans ; Hypoglycemic Agents/therapeutic use ; Insulin ; Male ; Retrospective Studies ; Rwanda/epidemiology
Chemical Substances	Blood Glucose ; Glycated Hemoglobin A ; Hypoglycemic Agents ; Insulin ; Glucose (IY9XDZ35W2)
Language	English
Publishing date	2022-10-08
Publishing country	England
Document type	Journal Article ; Randomized Controlled Trial
ZDB-ID	2091323-0
ISSN	1472-6823 ; 1472-6823
ISSN (online)	1472-6823
ISSN	1472-6823
DOI	10.1186/s12902-022-01162-9
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Article ; Online: Noncommunicable Diseases: The Authors Reply.

Kishore, Sandeep P / Belt, Rachel / Park, Paul H

Health affairs (Project Hope)

2015 Volume 34, Issue 11, Page(s) 2004

Language	English
Publishing date	2015-11
Publishing country	United States
Document type	Comment ; Letter
ZDB-ID	632712-6
ISSN	1544-5208 ; 0278-2715
ISSN (online)	1544-5208
ISSN	0278-2715
DOI	10.1377/hlthaff.2015.1222
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Article: Implementing the World Health Organization safe childbirth checklist in a district Hospital in Rwanda: a pre- and post-intervention study.

Tuyishime, Eugene / Park, Paul H / Rouleau, Dominique / Livingston, Patricia / Banguti, Paulin Ruhato / Wong, Rex

Maternal health, neonatology and perinatology

2018 Volume 4, Page(s) 7

Abstract: Background: Worldwide maternal mortality remains high, with approximately 830 maternal deaths occurring each day. About 90% of these deaths occur in low-income countries. Evidenced-based essential birth practices administered during routine obstetrical ... ...

Abstract	Background: Worldwide maternal mortality remains high, with approximately 830 maternal deaths occurring each day. About 90% of these deaths occur in low-income countries. Evidenced-based essential birth practices administered during routine obstetrical care and childbirth are key to reducing maternal and neonatal deaths. The WHO Safe Childbirth Checklist (SCC) is a low-cost tool designed to ensure birth attendants perform 29 essential birth practices (EBP) at four critical periods in the birth continuum. This study aimed to evaluate compliance with EBP in Masaka District Hospital both before and after the implementation of the WHO-SCC. Methods: This quality improvement project took place in the Masaka District Hospital in Rwanda. Observations of the 29 EBPs were done before and after WHO SCC implementation. The implementation process consisted of providing training in the use of the checklist to all clinical staff and posting SCC posters at different locations in the maternity unit. Results: A total 391 birth events were observed pre-intervention and 389 post-intervention. The overall EBP compliance rate increased from 46% pre-intervention to 56% post-intervention ( Conclusion: The implementation of the WHO SCC improved the overall EBP compliance rate in Masaka District Hospital. Determining the root cause of low compliance rate of some EBP may allow for more successful implementation of EBP interventions in the future. After further study, the SCC should be considered for scale up.
Language	English
Publishing date	2018-04-04
Publishing country	England
Document type	Journal Article
ZDB-ID	2809925-4
ISSN	2054-958X
ISSN	2054-958X
DOI	10.1186/s40748-018-0075-3
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Article ; Online: Addressing severe chronic NCDs across Africa: measuring demand for the Package of Essential Non-communicable Disease Interventions-Plus (PEN-Plus).

Boudreaux, Chantelle / Barango, Prebo / Adler, Alma / Kabore, Patrick / McLaughlin, Amy / Mohamed, Mohamed Ould Sidi / Park, Paul H / Shongwe, Steven / Dangou, Jean Marie / Bukhman, Gene

Health policy and planning

2021 Volume 37, Issue 4, Page(s) 452–460

Abstract: Severe chronic non-communicable diseases (NCDs) pose important challenges for health systems across Africa. This study explores the current availability of and demand for decentralization of services for four high-priority conditions: insulin-dependent ... ...

Abstract	Severe chronic non-communicable diseases (NCDs) pose important challenges for health systems across Africa. This study explores the current availability of and demand for decentralization of services for four high-priority conditions: insulin-dependent diabetes, heart failure, sickle cell disease, and chronic pain. Ministry of Health NCD Programme Managers from across Africa (N = 47) were invited to participate in an online survey. Respondents were asked to report the status of clinical care across the health system. A care package including diagnostics and treatment was described for each condition. Respondents were asked whether the described services are currently available at primary, secondary and tertiary levels, and whether making the service generally available at that level is expected to be a priority in the coming 5 years. Thirty-seven (79%) countries responded. Countries reported widespread gaps in service availability at all levels. We found that just under half (49%) of respondents report that services for insulin-dependent diabetes are generally available at the secondary level (district hospital); 32% report the same for heart failure, 27% for chronic pain and 14% for sickle cell disease. Reported gaps are smaller at tertiary level (referral hospital) and larger at primary care level (health centres). Respondents report ambitious plans to introduce and decentralize these services in the coming 5 years. Respondents from 32 countries (86%) hope to make all services available at tertiary hospitals, and 21 countries (57%) expect to make all services available at secondary facilities. These priorities align with the Package of Essential NCD Interventions-Plus. Efforts will require strengthened infrastructure and supply chains, capacity building for staff and new monitoring and evaluation systems for efficient implementation. Many countries will need targeted financial assistance in order to realize these goals. Nearly all (36/37) respondents request technical assistance to organize services for severe chronic NCDs.
MeSH term(s)	Anemia, Sickle Cell ; Chronic Disease ; Chronic Pain ; Diabetes Mellitus/therapy ; Heart Failure/therapy ; Humans ; Insulin ; Noncommunicable Diseases/therapy ; Primary Health Care
Chemical Substances	Insulin
Language	English
Publishing date	2021-12-17
Publishing country	England
Document type	Journal Article
ZDB-ID	632896-9
ISSN	1460-2237 ; 0268-1080
ISSN (online)	1460-2237
ISSN	0268-1080
DOI	10.1093/heapol/czab142
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