Decentralized Chronic Care Service Delivery for People Living with Type 1 Diabetes in Low- and Lower-Middle-Income...

The objective of this scoping review is to examine the published literature on the organization of type 1 diabetes care provision at primary and first-referral (generally district hospital level) facilities in low and lower-middle-income countries (LLMICs).

This scoping review searched 8 databases for published literature (2000-2024) describing service delivery for people living with type 1 diabetes in LLMICs at lower-level health facilities, resulting in 46 papers describing 40 studies.

Many studies include missing data, but available evidence suggests a lack of priority supplies and activities including ability to self-monitor blood glucose, basal-bolus insulin regimes, and A1C tests. Many studies reported specialized models, with diabetes clinics housed in outpatient departments, chronic care units, or noncommunicable disease clinics. Integrated approaches included diabetes care integrated into noncommunicable disease clinics or chronic care clinics, whereas nondifferentiated care in outpatient departments was reported in 2 studies. In one third of studies, clinic location could not be determined. Clinics were commonly staffed by midlevel providers, with variable reporting on training and mentoring. Patient education was described in most studies.

This review found a lack of evidence for critical components of intermediate diabetes management at most clinics in LLMICs, namely, the ability to self-monitor blood glucose, A1C testing, basal-bolus insulin regimens, peer support, social support, and comprehensive complication screening. The results of our review highlight both the urgent need for escalation to intermediate care in LLMICs and a need for standardized minimum reporting standards.