Implementation and evaluation of an insulin use manual in the public health system of a Peruvian Region: a mixed-methods study

BACKGROUND: Diabetes is a major public health issue, especially in low-and middle- income countries (LMICs) where barriers to care are common. Despite insulin's critical role, access remains limited due to market concentration, weak policies, poor availability, and lack of trained staff. This study evaluated the implementation of an insulin use manual in Tumbes, Peru, focusing on healthcare workers training and systemic barriers. METHODS: This was a two-phase descriptive mixed-methods study conducted in Tumbes, Peru. In the first phase (March-June 2023), a virtual course on insulin use followed by an on-site workshop was implemented for healthcare workers, with quantitative assessments of knowledge and satisfaction. In the second phase (October 2023), qualitative interviews were carried out with these healthcare workers as well as patients and caregivers to evaluate both the implementation process and the local health system using the Rapid Assessment Protocol for Insulin Access, Medical Research Council for Process Evaluation, and the World Health Organization (WHO)'s Six Building Blocks framework. Data were analyzed with descriptive statistics and thematic coding. RESULTS: The virtual course registered 193 participants, but only 44 completed all units, the median knowledge median scores rose from 15.3 to 19.1). In the on-site workshop, 28 participants attended. Median scores increased from 14 (IQR 10-16) at baseline to 15 (IQR 10-16) in the post-test. Feedback highlighted the course's flexibility and practical relevance, though participants suggested more hands-on components and patient education tools. Interviews revealed systemic barriers across WHO's Six Building Blocks framework, including limited training and confidence among healthcare workers in insulin management, shortages of insulin and related supplies at the primary care level, weak health information systems without proper tracking of insulin users; high out-of-pocket costs that undermine adherence, inadequate patient education, and insufficient leadership and supervision to ensure consistent diabetes care. CONCLUSIONS: This study shows that while targeted training can improve healthcare workers' knowledge on insulin use, systemic gaps continue to hinder quality diabetes care. Broader implementation of insulin protocols in LMICs requires not only training, but also a comprehensive reinforcement of the health system at all levels.