Type 2 diabetes is among one of the foremost challenges facing policymakers in Thailand. It accounts for considerable death, disability and healthcare expenditure. Under Thailand’s strong primary health system, medical management of diabetes is widely available. However, control of blood glucose and other cardiovascular disease risk factors, and regular screening for early detection for complications remain low due to a lack of services for education and counselling to support the individual behavioural changes necessary for good self-management of the condition.
Medical management vs self-management
Medical management primarily focuses on clinical interventions, such as clinicians prescribing medication and monitoring blood glucose levels to control diabetes. Diabetes self-management education (DSME) focuses on the empowerment and education of the individual to effectively manage their own diabetes care. The person with diabetes learns how to take control of their own long-term condition; they are educated in what diabetes is, nutrition, the importance of physical activity, and how to monitor their blood glucose levels. Developing skills and knowledge for day-to-day management. This can lead to improved short- and long-term outcomes, which includes better quality of life and reduces risk of complications such as cardiovascular disease, nerve, eye, foot and kidney damage.
While there is a lot of research to support the effectiveness of DSME, there is little data available for Thailand, and traditional modes of delivering this education, such as a health professional leading one-to-one or small-group sessions, are not scalable in Thailand due to resource and budgetary constraints.
Iliatha Papachristou Nadal worked with Chiang Mai University in Thailand to develop a low-cost DSME programme, one that was culturally tailored for Thailand and evaluated its clinical and cost-effectiveness with two delivery modes: nurse-led and peer-led.
The main challenge was getting buy-in from the different stakeholders, including healthcare directors where the intervention would be implemented, as well as the clinicians and healthcare volunteers who would be facilitating the DSME tools. From the beginning, the team liaised with the Thai Ministry of Health (MOH) with representatives from the MOH attending stakeholder meetings. The team were keen to have the intervention applied into practice and, together with the health directors, negotiated where the intervention would be best implemented, namely in primary care units delivered by the nurses in the first instance.
Designing a DSME programme for Thailand
To design the education material, Iliatha first scoped the literature for existing DSME programmes both internationally and locally within Thailand. This allowed her to see what a DSME programme should consist of, including the material. This was discussed and adapted at stakeholder workshops and public engagement meetings, going through several iterations before being finalised.
Four modules were created: a general overview of diabetes, treatment targets and goal setting; diet and nutrition; physical activity and exercise; stress management and mental health. The latter was a new unique component created by Iliatha, addressing the unique mental health demands that the condition poses to people dealing with it.
To accompany these modules, which would be delivered by nurses and village health volunteers, researchers created six short films. Animations and short films are increasingly recognised as an effective way of communicating and enhancing recall in low literacy settings; the films developed for this project were in the local language and utilised local people.
Scaling the solution
The programme was originally conducted in two provinces in Northern Thailand: Chiang Mai and Lampang, reaching a total of 21 primary care units.
It has continued after the initial research study, and the culturally tailored education programme is now accessible across three Northern Thailand provinces. As well as reaching over 250 primary care units and over 8000 patients with type 2 diabetes, the research has raised public awareness to patients with type 2 diabetes, including those from low socio-economic backgrounds, those with low literacy levels and across urban and rural areas.
The programme has also created a large peer support network for the patients, and provided clinicians and healthcare volunteers with the tools to enhance and develop specialised skills in diabetes management.
Continuing impact
The team are in discussions with the MOH in Thailand to implement this programme at a national level and are expected to have a major policy impact due to the close involvement of a key policy maker throughout the project.
The work has also been a starting point for a new intervention for lifestyle counselling delivered by non-health professionals, namely healthcare volunteers and peer models. This has also been in collaboration with the MOH; based on the team’s work here, the ministry has expressed interest in having healthcare volunteers trained in motivational interviewing to further support diabetes patients.
It has been an exciting opportunity to work with the team in the Department of Family Medicine, Chiang Mai University and be a part of the development and implementation of Thai diabetes education that has now been scaled up to multiple provinces across the country.
We have made a difference to the way health care professionals approach diabetes education as well as helping those with type 2 diabetes to manage their health and wellbeing. Seeing one's work being applied within the health care system is really motivating.
Iliatha Papachristou Nadal
