Scalable solution for delivery of diabetes self-management education in Thailand (DSME-T): a cluster randomised trial study protocol

Development of a tool to estimate sugar and caloric contents in alcoholic beverages for a diabetes self-management program in Thailand

Diabetes self-management education and support (DSMES) is recommended as a standard of care for patients with diabetes worldwide. Alcohol consumption is one aspect mentioned within the DSMES program in Thailand where alcohol consumption is the highest among Southeast Asian countries. Many diabetes guidelines suggest limiting alcohol intake to not more than one standard drink per day for adult women and two for adult men if they cannot abstain from drinking. In practice, however, the conversion of alcohol consumption into standard drinks, and nutritional information about the calorie and sugar contents of alcoholic beverages, especially domestically produced spirits, are not commonly available in Thailand. By reviewing the diabetes guidelines internationally and the Thailand alcoholic beverage industry, a visual health education tool to help convert different alcoholic beverages into standard drinks and to provide the calorie and sugar content of alcoholic beverages was developed as a part of the DSMES program. It was finalized following pilot testing and focus group discussions with policymakers, healthcare providers, and type 2 diabetes patients. The personalized counseling tool, integrated with guidelines and culturally tailored to the Thai setting is distributed to counselors/educators. It is a potentially useful tool for patients to make informed choices for their self-management of diabetes.

Knowledge on diabetes and its related factors among the people with type 2 diabetes in Thailand: a cross-sectional study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a global public health problem with complications related to knowledge guiding self-care. Limited knowledge might result in poor control of blood glucose, but there is no previous investigation measuring diabetes knowledge in people diagnosed with T2DM in Thailand. This study was aimed to investigate level of diabetes knowledge and related factors among people with T2DM in Thailand.

METHOD

This cross-sectional study was conducted in a Northeastern province in Thailand among 276 people with T2DM, 195 women and 81 men, using a standardized self-report questionnaire, the Diabetes Knowledge Test. The data were analyzed using Pearson's chi-square test, one-way analysis of variance, and independent samples t-test.

RESULTS

The majority of respondents had poor diabetes knowledge in all subscales; total knowledge of diabetes (96.7%), general knowledge of diabetes (71.7%), and insulin use knowledge (92.3%). There was no difference found in knowledge scores between males and females. Having finished secondary school education or higher, being employed, or having diabetes-related complications were related to increased total diabetes knowledge and general diabetes knowledge.

CONCLUSION

The people with T2DM had poor diabetes knowledge, and those using insulin also had poor knowledge about the use of insulin.

Advancing multimorbidity management in primary care: a narrative review

BACKGROUND

Multimorbidity, defined as the coexistence of two or more chronic conditions in the same individual, is becoming a crucial health issue in primary care. Patients with multimorbidity utilize health care at a higher rate and have higher mortality rates and poorer quality of life compared to patients with single diseases.

AIMS

To explore evidence on how to advance multimorbidity management, with a focus on primary care. Primary care is where a large number of patients with multimorbidity are managed and is considered to be a gatekeeper in many health systems.

METHODS

A narrative review was conducted using four major electronic databases consisting of PubMed, Cochrane, World Health Organization database, and Google scholar. In the first round of reviews, priority was given to review papers summarizing the current issues and challenges in the management of multimorbidity. Thematic analysis using an inductive approach was used to build a framework on how to advance management. The second round of review focused on original articles providing evidence within the primary care context.

RESULTS

The review found that advancing multimorbidity management in primary care requires a health system approach and a patient-centered approach. The health systems approach includes three major areas: (i) improves access to care, (ii) promotes generalism, and (iii) provides a decision support system. For the patient-centered approach, four key aspects are essential for multimorbidity management: (i) promoting doctor-patient relationship, (ii) prioritizing health problems and sharing decision-making, (iii) supporting self-management, and (iv) integrating care.Advancement of multimorbidity management in primary care requires integrating concepts of multimorbidity management guidelines with concepts of patient-centered and chronic care models. This simple integration provides an overarching framework for advancing the health care system, connecting the processes of individualized care plans, and integrating care with other providers, family members, and the community.

Illness perceptions, self-care practices, and glycemic control among type 2 diabetes patients in Chiang Mai, Thailand

BACKGROUND

Diabetes Self-Management Education (DSME) is a fundamental aspect of diabetes care, but no standard program exists in Thailand. Understanding current patterns of illness perceptions (concerns) and self-management practices among patients with diabetes in Thailand is vital to develop culturally tailored DSME programs. This study sought to explore the association between reported self-management practices and diabetes perceptions on glycemic control among patients with type 2 diabetes in Chiang Mai Province, Thailand. Specifically, the study examined whether the association between illness perceptions and diabetes control was mediated by self-management.

METHODS

This was a cross-sectional study conducted among type 2 diabetes patients on outpatient care and follow-up in four districts hospitals in Chiang Mai, Thailand. Illness perceptions was measured by the Brief Illness Perceptions Questionnaire (BIPQ). Self-management practices were measured by Summary Diabetes Self-Care activities (SDSCA). For illness perceptions and self-management practices, patients were classified into two groups, high level and low level based on the median values. Univariate and multivariable analyses were done to determine the association between the determinant factors: self-care practices and illness perceptions and the outcome of interest- good glycemic control (HbA1c < 7%).

RESULTS

Of the 200 participants recruited into the study, 180 completed the questionnaire. Only 35% of participants had good glycemic control (HBA1c < 7.0). Both illness perceptions and self-management practices were independently linked to glycemic control. Among illness perceptions, a sense of personal control was strongly associated with good glycemic control (p = 0.01). For self-management, appropriate diet (p = 0.03) and medication adherence (p = 0.05) were associated with good glycemic control. After adjustments for key baseline characteristics, patients with high levels of illness perceptions were less likely to achieve glycemic control (OR 0.55, 95% CI 0.29 to 1.14, p = 0.11) and those with high level of self-management were more likely to achieve glycemic control (OR 2.11, 95% CI 1.04 to 4.30, p = 0.04). The effect size for illness perception attenuated when further adjusted for levels of self-management (OR 0.88, 95% CI 0.39 to 1.96, p = 0.75) while the effect size for self-management and glycemic control did not materially change (OR 2.30, 95% CI 1.06 to 5.02, p = 0.04).

CONCLUSION

Illness perceptions and self-management practices are associated with glycemic control. Future culturally tailored interventions in Thailand aimed at improving glycemic should focus on personal control, improving diet and treatment adherence as these are more likely to help improve diabetes control as demonstrated in this study.

Process evaluation protocol of a cluster randomised trial for a scalable solution for delivery of Diabetes Self-Management Education in Thailand (DSME-T)

INTRODUCTION

Type 2 diabetes mellitus is a major global challenge, including for Thai policy-makers, as an estimated 4 million people in Thailand (population 68 million) have this condition. Premature death and disability due to diabetes are primarily due to complications which can be prevented by good risk factor control. Diabetes Self-Management Education (DSME) programmes provide patients with diabetes with the necessary knowledge and skills to effectively manage their disease. Currently, a trial is being conducted in Thailand to evaluate the effectiveness, defined as HbA1c<7 at 12 months after enrolment, of a culturally tailored DSME in Thailand. A process evaluation can provide further interpretation of the results from complex interventions as well as insight into the success of applying the programme into a broader context.

METHODS AND ANALYSIS

The aim of the process evaluation is to understand how and why the intervention was effective or ineffective and to identify contextually relevant strategies for future successful implementation. For the process evaluation, the design will be a mixed-method study collecting data from nurse providers, and village health volunteers (community health workers) as well as patients. This will be conducted using observations, interviews and focus groups from the three purposively selected groups at the beginning and end of trial. Quantitative data will be collected through surveys conducted at the beginning, during 6-month follow-up, and at the end of trial. The mixed-methods analysis will be triangulated to assess differences and similarities across the various data sources. The overall effectiveness of the intervention will be examined using multilevel analysis of repeated measures.

ETHICS AND DISSEMINATION

Study approved by the Chiang Mai University Research Ethics Committee (326/2018) and the London School of Hygiene & Tropical Medicine (16113/RR/12850). Results will be published in open access, peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT03938233.