The Challenges of Iran's Type 2 Diabetes Prevention and Control Program

Health indicators in the management of diabetes in Primary health care: Iran-package of Essential Non-communicable diseases (IraPEN) program

Objectives

This study evaluated the effectiveness of the IraPEN program, an adapted version of the WHO Package of Essential Non-communicable Disease (PEN) intervention, in managing diabetes from September 2020 to September 2021 using the Input-Process-Output-Outcome framework.

Methods

In this Cross-sectional/Ecological study, aggregated data was collected from IraPEN facilities by medical universities using the electronic health system. The data was presented as numbers and proportions, for urban and rural healthcare facilities separately.

Results

The study surveyed 610 NCD facilities from184 comprehensive health centers under the supervision of 56 medical universities, which provided services to 1,785,226 individuals aged > = 30 years. In terms of input/process, 78% of NCD facilities had functional point-of-care testing, and 14% of health centers with drugstore experienced a stock-out of core medications during the past three months. In urban facilities, 66% had at least a trained nutritionist, and 82% trained psychologist. Regarding output/outcome, 26% of expected diabetes and 23% of expected pre-diabetes, as estimated by the STEPS 2016 survey, were enrolled in NCD facilities, with higher rates in rural than urban areas. Among the referred patients, 38.7% took statins, 53% visited a physician in the last three months, 57.2% were referred for dietary assessment, and 72.5% were referred to secondary care. Around 39% of diabetic patients with at least one HbA1c laboratory test had good glycemic control.

Conclusions

The IraPEN program has managed only a quarter of diabetic patients, and less than half of them are in good glycemic control. Urgent improvements, mainly in coverage and effectiveness, are necessary.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-024-01550-z.

Evaluation of the diabetes care cascade and compliance with WHO global coverage targets in Iran based on STEPS survey 2021

This study aimed to investigate the diabetes mellitus (DM) and prediabetes epidemiology, care cascade, and compliance with global coverage targets. We recruited the results of the nationally representative Iran STEPS Survey 2021. Diabetes and prediabetes were two main outcomes. Diabetes awareness, treatment coverage, and glycemic control were calculated for all population with diabetes to investigate the care cascade. Four global coverage targets for diabetes developed by the World Health Organization were adopted to assess the DM diagnosis and control status. Among 18,119 participants, the national prevalence of DM and prediabetes were 14.2% (95% confidence interval 13.4-14.9) and 24.8% (23.9-25.7), respectively. The prevalence of DM treatment coverage was 65.0% (62.4-67.7), while the prevalence of good (HbA1C < 7%) glycemic control was 28.0% (25.0-31.0) among all individuals with diabetes. DM diagnosis and statin use statics were close to global targets (73.3% vs 80%, and 50.1% vs 60%); however, good glycemic control and strict blood pressure control statistics, were much way behind the goals (36.7% vs 80%, and 28.5% vs 80%). A major proportion of the Iranian population are affected by DM and prediabetes, and glycemic control is poorly achieved, indicating a sub-optimal care for diabetes and comorbidities like hypertension.

Challenges to Lifestyle Medicine for Type 2 Diabetes in Iran: A Synoptic Review

Type 2 diabetes (T2D) is a major public health issue in Iran. The principal context for T2D management is the prevention of cardiovascular disease development and progression. These preventive strategies can be enhanced with routine implementation of comprehensive lifestyle modification, guideline-directed medical therapies, and creation of infrastructure that considers social determinants of health, ethnocultural variables, and financial challenges. In this synoptic review, scientific evidence sourced from Iran is analyzed to identify tactics to optimize the lifestyle medicine component of T2D care in Iran. Important evidence-based factors gleaned from the literature were curated into 9 categories: self-care, dietary adherence, mental health, self-comparison, transcultural adaptation, family support and community engagement, physical activity, the global pandemic, and service delivery. These categories were then assigned to 1 of 4 a priori aspects challenging diabetes care in Iran: behavioral factors, belief system, drivers, and implementation. By codifying discussion points and individual tactics, the improvement and optimization of T2D care in Iran can be facilitated. This reductionist model of approaching lifestyle medicine and complex chronic disease such as T2D can be applied to other ethnocultural populations.

Barriers Toward the National Program for Prevention and Control of Diabetes in Iran: A Qualitative Exploration

BACKGROUND

Despite the achievements of the national program for the prevention and control of diabetes (NPPCD) over the past two decades, the available evidence indicates a high prevalence of this disease in Iran. This qualitative study aims to investigate barriers to the NPPCD by pursuing the perspectives of relevant policy-makers, planners, and healthcare workers.

METHODS

A grounded theory approach was used to analyze participants' perceptions and experiences. Semi-structured interviews (n=23) and eight focus groups (n=109) were conducted with relevant policy-makers, planners, and healthcare workers in charge of Iran's national diabetes management program. Of the 132 participants, ages ranged from 25 to 56 years, and 53% were female. Constant comparative analysis of the data was conducted manually, and open, axial, and selective coding was applied to the data.

RESULTS

Two main themes emerged from data analysis: implementation barriers and inefficient policy-making/ planning. Insufficient financial resources, staff shortage and insufficient motivation, inadequate knowledge of some healthcare workers, and defects in the referral system were recognized as the NPPCD implementation barriers. Inappropriate program prioritizing, the lack of or poor intersectoral collaboration, and the lack of an effective evaluation system were the inefficient policy-making/planning problems.

CONCLUSION

Current results highlighted that inefficient policy-making and planning have led to several implementation problems. Moreover, the key strategies to promote this program are prioritizing the NPPCD, practical intersectoral collaboration, and utilizing a more efficient evaluation system to assess the program and staff performance.

Comparison of cognitive status of diabetic and non-diabetic elderly in the last ten years in primary health care in Iran

Introduction. Cognitive disorders and chronic diseases such as diabetes are common problems of aging. The aim of this study was to determine and compare the cognitive status of diabetic and non-diabetic elderly in the past ten years in primary health care in Iran. Method: This cross-sectional study was performed on people aged 60 years and older in Kerman, Iran in 2020. In total, this study was performed on 200 patients (100 diabetic and 100 non-diabetic) meeting inclusion criteria. The Short Mental Status Questionnaire (MMSE) and The Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) were used to assess cognitive function. The validity and reliability of the questionnaires were confirmed in this study. Data were analyzed using Chi-square, T-test, and ANOVA analysis in SPSS 21 software. Results. The results showed that there was a statistically significant difference between diabetic and non-diabetic groups in the current cognitive status and cognitive status in the last ten years. The mean scores of cognitive function from the short mental status questionnaire in the diabetic group were lower than in the non-diabetic group (p = 0.001). The mean scores of the cognitive deficit screening questionnaire in diabetic elderly were higher than in non-diabetic elderly (p < 0.001). Conclusion. Based on the results of this study, health care providers and family physicians should focus on controlling diabetes and identifying any cognitive impairment in the early stages of comprehensive care of diabetic patients.

Identifying associations between health services operational factors and health experience for patients with type 2 diabetes in Iran

Background

Facing limited health resources, healthcare providers need to rely on health service delivery models that produce the best clinical outcomes and patient experience. We aimed to contribute to developing a patient experience-based type 2 diabetes service delivery model by identifying operational structures and processes of care that were associated with clinical outcome, health experience, and service experience.

Methods

We conducted a cross-sectional survey of type 2 diabetes patients between January 2019 to February 2020. Having adjusted for demand variables, we examined relationships between independent variables (behaviours, services/processes, and structures) and three categories of dependent variables; clinical outcomes (HbA1c and fasting blood glucose), health experience (EuroQol quality of life (EQ-5D), evaluation of quality of life (visual analgene scale of EQ-5D), and satisfaction with overall health status), and service experience (evaluation of diabetes services in comparison with worst and best imaginable diabetes services and satisfaction with diabetes services). We analysed data using multivariate linear regression models using Stata software.

Results

After adjusting for demand variables; structures, diabetes-specific health behaviours, and processes explained up to 22, 12, and 9% of the variance in the outcomes, respectively. Based on significant associations between the diabetes service operations and outcomes, the components of an experience-based service delivery model included the structural elements (continuity of care, redistribution of task to low-cost resources, and improved access to provider), behaviours (improved patient awareness and adherence), and process elements (reduced variation in service utilization, increased responsiveness, caring, comprehensiveness of care, and shared decision-making).

Conclusions

Based on the extent of explained variance and identified significant variables, health services operational factors that determine patient-reported outcomes for patients with type 2 diabetes in Iran were identified, which focus on improving continuity of care and access to providers at the first place, improving adherence to care at the second, and various operational process variables at the third place.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06932-0.

Is Telenursing an Effective Method to Control BMI and HbA1c in Illiterate Patients Aged 50 Years and Older With Type 2 Diabetes? A Randomized Controlled Clinical Trial

Introduction: Telenursing is a simple method to provide and maintain nursing care for patients with chronic illness such as diabetes. This study aimed to determine the effectiveness of telenursing on body mass index (BMI) and glycosylated hemoglobin (HbA1c) in illiterate patients aged 50 years and older with type 2 diabetes.

Methods: A randomized controlled clinical trial was performed. Sixty patients with type 2 diabetes who referred to Aligoodarz diabetes clinic (Lorestan, Iran) were randomly assigned to the intervention and control group. Each patient was assessed before and after intervention for the following clinical parameters: HbA1c by Drew-DS5 analyzer and weight by scale (Sahand BMI electronic scale /Iran). All patients received diabetes self-care training for 3 days before the study. Telephone follow ups were applied in intervention group for 12 weeks. The data were analyzed using chi-square, paired t test and independent t test by SPSS11.

Results: Results showed statistically significant decrease in BMI at the end of the training from 29.28 (3.29) to 28.35 (3.37) kg/m 2 and statistically significant decrease in HbA1c from 8.96 (1.24) to 7.56 (0.71) in the intervention group. The effect size base on Cohen’s formula for BMI and HbA1c was Cohen’s d = 2.85, effect size r = 0.81 and Cohen’s d = 2.04, effect size r = 0.71, respectively.

Conclusion: The findings indicate that nurse-led telephone follow up can increase adherence from treatment program and has beneficial effects on HbA1c and BMI in illiterate patients aged 50 years and older with type 2 diabetes.

Challenges of managing diabetes in Iran: meta-synthesis of qualitative studies

Background

Although several diabetes management and control programmes are introduced in Iran, many patients do not achieve diabetes-related clinical goals as recommended. The aim of this study was to identify the qualitative evidence for the challenges regarding diabetes management.

Methods

A systematic review of qualitative studies following PRISMA guidelines was undertaken. Scopus, PubMed, Science Direct, and Web of Knowledge were searched as well as Persian databases including Magiran, Irandoc and SID from inception to August 2019. The included Studies were either in English- or Persian-language qualitative studies reporting the perspectives of patients, their relatives, or healthcare service providers. Content of the findings were analysed and organized according to Chronic Care Model framework.

Results

Twelve studies met the inclusion criteria. Six main themes were identified including holistic understanding of patients, leadership and governance difficulties, service delivery, workforce, financing, and information and research.

Conclusion

Challenges regarding the management of diabetes in Iran is multifaceted. Reforming the health care system or developing complementary strategies is essential to improve suitable health care model for patients with chronic conditions such as diabetic patients.