Key messages
• Providing care for children and adolescents with type 1 diabetes mellitus (T1DM) in low- and middle-income countries (LMICs) is challenging due to limited resources and access to treatment.
• Many countries have implemented T1DM care models supported by international initiatives, yet several barriers, such as financial constraints and lack of comprehensive care, persist.
• Sustained efforts are needed to ensure that young people with T1DM receive consistent and effective care to improve their quality of life and health outcomes.
What is type 1 diabetes mellitus (T1DM)?
T1DM is a chronic condition where the body cannot produce insulin, a hormone necessary to regulate blood sugar. Without proper management, T1DM can lead to severe complications, including blindness and kidney failure, and early death.
How is T1DM treated?
T1DM is managed through insulin therapy, regular blood sugar monitoring, and lifestyle adjustments, including diet and physical activity. Comprehensive care involves access to medications, diabetes education, and support from healthcare professionals.
What did we want to find out?
We aimed to explore and summarise how care for T1DM in children and adolescents (up to 18 years old) is organised and delivered in LMICs, focusing on aspects such as composition of healthcare teams, access to treatment, and provision of self-management support.
What did we do?
We conducted a scoping review of studies describing models of care for T1DM in children and adolescents in LMICs. We analysed data from 40 studies covering 19 countries across six World Health Organization (WHO) regions to identify common practices and challenges.
What did we find?
Models of care varied widely across countries and regions.
• Africa: programs in Cameroon, Kenya, Rwanda, Tanzania, and Uganda have improved infrastructure and provided free insulin, blood sugar monitoring supplies, and education. However, financial and logistical challenges persisted.
• Americas: Brazil and Cuba focused on reducing complications and improving psychosocial support, but patient outcomes were not documented.
• South-East Asia: Bangladesh, India, Myanmar, Sri Lanka, and Thailand have implemented care models supported by international initiatives. However, financial barriers remained.
• Europe: Kazakhstan and Turkey provided free insulin and supplies.
• Eastern Mediterranean: Morocco expanded care delivery to provincial hospitals and emphasised self-management education.
• Western Pacific: Cambodia, Malaysia, Vietnam, and Laos received support from the Action4Diabetes program, which improved access to insulin and patient monitoring.
What are the limitations of the evidence?
A lack of standardised evaluation and reporting limits the available evidence. Most studies focused on describing care models and did not assess their long-term impact on patient health. Financial sustainability and access disparities were common challenges.
How up to date is this evidence?
The evidence is current to December 2023.
Read the full abstract
In order to improve the outcomes of children and adolescents with type 1 diabetes mellitus (T1DM), access to and quality of comprehensive acute and chronic care services in low- and middle-income countries (LMIC) must be improved.
Objectives
To identify and summarise the characteristics of models of care for T1DM in children and adolescents in LMIC.
Search strategy
We searched MEDLINE, Scopus, the Cochrane Central Register of Controlled Trials (CENTRAL), and the World Health Organization (WHO) Global Index Medicus from inception to 11 December 2023 without restrictions.
Selection criteria
We conducted a scoping review following the Joanna Briggs Institute guidelines. We included all study types describing the implemented organisation (setting, healthcare facilities, financial resources) and delivery of T1DM care (treatment, self-management support, clinical monitoring) for the management of T1DM in children and adolescents in LMIC.
Data collection and analysis
Two review authors independently screened and selected eligible studies, and charted relevant data from the included studies. The charted data were presented in a descriptive format.
Main results
We included 40 studies that described models for T1DM care in 19 LMICs across the different WHO regions.
African Region
We identified models of care in Cameroon, Kenya, Rwanda, Tanzania, and Uganda, largely supported by international initiatives like Changing Diabetes in Children (CDiC) and Life for a Child (LFAC). Models were implemented between 2004 and 2012, and aimed to enhance infrastructure and care delivery, including access to insulin, glucose monitoring supplies, and diabetes education for patients and caregivers. Multidisciplinary teams provided care across urban and rural settings, with some countries offering tele-support and diabetes camps. Financial and logistical barriers persisted despite governmental and humanitarian support.
Region of the Americas
We identified models of care in Brazil and Cuba, focusing on reducing complications, training human resources, and supporting psychosocial development. In Brazil, care was delivered at a secondary-level facility by a multidisciplinary team. In Cuba, care was provided by a tertiary-level childhood diabetes clinic. Both models emphasised diabetes education for patients and families, regular specialist consultations, and community awareness initiatives. Unique features included holiday camps in Cuba and internship programs for healthcare professionals in Brazil. Diabetes care in Brazil was free, with additional resources for those in need.
South-East Asia Region
We identified models of care in Bangladesh, India, Myanmar, Sri Lanka, and Thailand, with implementation between 2009 and 2015. These models aimed to improve access to care, self-management education, and awareness amongst healthcare workers and communities, particularly for children below the poverty line. Supported by initiatives such as CDiC, LFAC, and Action4Diabetes (A4D), the models delivered outpatient care through multidisciplinary teams, providing free insulin and supplies in most countries. Regular HbA1c monitoring, diabetes education, and psychological support were key components, along with community awareness initiatives in four countries. Financial barriers remained significant, particularly in Bangladesh and Thailand.
European Region
We identified models of care in Kazakhstan and Turkey, aiming to provide comprehensive diabetes care and improve patient well-being. In Kazakhstan, care included free insulin, glucose meters and test strips, and a monitoring system for hypoglycaemia and diabetic ketoacidosis was in place. Turkey’s National Childhood Diabetes Program, initiated from 1994 onwards, delivered care through multidisciplinary healthcare teams and included initiatives like the Diabetes at School Program to raise awareness. Financial barriers persisted in both countries concerning certain supplies and technologies.
Eastern Mediterranean Region
We identified a model of care in Morocco, implemented in 1986, that had expanded from a single tertiary-level facility to nine provincial secondary-level hospitals, covering a third of the country’s young patients with T1DM. Care was delivered by multidisciplinary teams and included initial in-hospital treatment, followed by outpatient consultations every three months. Education in self-management was emphasised, with group sessions, holiday camps, and tailored resources for illiterate parents. A database system supported electronic data monitoring. Financial support was provided for low-income families through sponsors and associations, although insurance coverage was limited to insulin costs.
Western Pacific Region
We identified models of care for Cambodia, Malaysia, Vietnam, and Laos, supported by the A4D program. T1DM care included free insulin, glucose meters, HbA1c testing, and emergency funds, with care delivered through tertiary and secondary-level facilities, except in Vietnam where a single tertiary-level clinic provided care. Multidisciplinary teams were present in Cambodia, Malaysia, and Vietnam, but not in Laos. Screening for diabetes complications varied, with the most comprehensive screening offered in Cambodia and Laos. Ongoing diabetes training for healthcare workers, and electronic patient databases were integral to the model of care. Financial barriers persisted in Laos, where certain screening assessments required out-of-pocket payment.
Authors' conclusions
In many countries included in this review, substantial improvements in T1DM care have been made, particularly through international partnerships. However, the sustainability, consistency, and comprehensiveness of care remain a consistent challenge for further improving life expectancy and quality of life for children and adolescents with T1DM.
Funding
World Health Organization (WHO)
Registration
Registration: OSF, via doi.org/10.17605/OSF.IO/JZ65G
