diabetes

Although guidelines for best practice in diabetes care are readily available, including the IDF Global Guideline on Type 2 Diabetes, and there are several frameworks to guide their implementation, it remains a challenge in all countries to bridge the gap between actual and optimal care.

Investments in education and change

One important part of any solution is education. Diabetes-specific education is required for healthcare personnel and people with diabetes; and in addition training is needed to help them integrate new knowledge and transform old practices. The latter is essential if clinical outcomes for people with diabetes are to be improved. It has been shown that without a purposeful, planned method of changing clinical or personal behaviour, very little happens. Investment must be made not only to ensure specialized diabetes education is accessible to healthcare personnel and people with diabetes but also to ensure both groups are trained in how to implement change 1 2 .

Ministries of Health and health administrators need to recognize and give support to the special healthcare needs of people with diabetes 1 and this includes designing health systems that facilitate best practice 2 . Providing good diabetes care for a population requires the coordination of the health systems across three levels. At the centre of all care is the person with diabetes, their family and their immediate carers. At the middle level is the community and healthcare organizations within which care is delivered. Effective functioning across the providers needed to care for people with diabetes requires supporting policy and financial frameworks. The World Health Organisation’s Innovative Care for Chronic Conditions Framework 3 provides guidance on the relationships between, and the contents of, these three levels. This framework was designed to be helpful within different resource settings, rich to poor, and has been developed with suggested methods of quality improvement to incrementally strengthen health systems for diabetes and other chronic diseases (see Beyond Access to Insulin).

Modern improvement processes have had positive results in many countries, including Canada, USA, United Kingdom, Ghana, Malawi, South Africa, Russia and Peru. A critical factor in their success is that they develop and implement solutions specific to the realities of their settings 2 . Reorganization of current resources or addition of new resources may be required to fill overt gaps in care, such as interdisciplinary teams specially trained to provide diabetes self-management education and follow-up or access to essential medicines packaged with education to support their use. The advancement of diabetes care relies not only on increased knowledge and behaviour change but also on using proven methods to advance health systems to support best practice 4 .

Self-management education and support

"Diabetes self-management education (DSME) and ongoing self-management support are critical components of effective diabetes care, and significant contributors to metabolic and psychological outcomes." 5 In many areas of the world people with diabetes cannot access this essential treatment. Interactive DSME is essential for people with diabetes to understand their condition, protect themselves from harm and make lifestyle changes to optimize their health. To design an accessible programme, funding needs to be provided for healthcare personnel with specialized training in DSME. Programmes must be locally affordable, offered in areas accessible to the target population, delivered at appropriate literacy levels and be culturally relevant. Diabetes self-management education and diabetes self-management support must be available and accessible for people with diabetes if optimal outcomes are to be achieved 5 .

People with diabetes have the right to understand their disease, make informed choices and receive care based on best practice. They must be part of the team that manages their condition.This can only be achieved if interdisciplinary teams and people with diabetes have the information and tools to make changes based on best practice and recognized improvement strategies are used to support meaningful system change.

Text box 4.4 Survey on diabetes education practices

A survey was carried out by the IDF Consultative Section on Diabetes Education in 2008 to gain a deeper appreciation for diabetes education practices worldwide and to provide a preliminary look at diabetes education in specific areas. The purpose of the survey was to capture responses from providers regarding practice setting, descriptions of diabetes teams, resources for diabetes education, community services and barriers to diabetes education.

The survey questionnaire was based on the structural and process standards for diabetes health education defined in the IDF’s International Consensus Standards for Diabetes Education 6 , which provide a benchmark against which the quality of DSME programmes can be evaluated.

The surveys were completed by healthcare professionals selected to participate in train-the-trainer sessions. The survey respondents represented healthcare institutions in the IDF African, European, Middle East and North African, North America and Caribbean, and South and Central American Regions.

Survey results

The survey results provide preliminary data on the status of diabetes education in the different regions. Forty-five out of 55 participants responded, giving a response rate of 82%. Respondents represented 26 countries in the five regions.

The results indicated that diabetes education was integrated into national diabetes programmes in two-thirds of the countries which had such a programme. The results also showed that diabetes education was practised in a variety of settings by many different healthcare providers. When asked about the most significant barriers to diabetes education, lack of resources in terms of the number of diabetes educators from the systems perspective was most often cited (see Figure 4.1). Another important barrier was that people with diabetes did not have time or support from employers to pursue diabetes education. The results also confirm that despite the presence of national diabetes programmes, people with diabetes may not have access to adequate education and care.

These data are limited by the sample chosen to participate and should not be considered statistically representative. However, the respondents do provide insight into their perception of diabetes education in their country. Despite the limitations of the survey, the results demonstrate a clear need for increased numbers of diabetes educators and support for diabetes self-management education for people with diabetes.

1: World Health Organization. Innovative Care for Chronic Conditions: Building Blocks for Action. Global Report. Geneva: World Health Organization; 2002. http://www.who.int/diabetesactiononline/about/icccreport/en/
2: Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282 (15): 1458-1465.
3: Jordan EJE, Pruitt SD, Bengoa R, et al. Improving the quality of health care for chronic conditions. Quality and Safety in Health Care 2004; 13 (4): 299-305.
4: World Health Organization. 2008-2013 Action Plan for the Global Strategy for the prevention and control of non-communicable disease. Geneva: World Health Organization; 2008. www.who.int/nmh/Actionplan-PC-NCD-2008.pdf
5: Berwick DM. Lessons from developing nations on improving health care. BMJ 2004; 328 (7448): 1124-1129.
6: IDF Consultative Section on Diabetes Education International Consensus Standards for Diabetes Education 2003