Diabetes mellitus (DM) refers to a group of metabolic conditions characterized by unusual high blood glucose levels with impairment in carbohydrates, protein and fat metabolism due to abnormalities in insulin secretion, insulin response or both(1). World Health Organization (WHO) devides DM into two types: type 1 and type 2(1). Type 1 DM is characterised by immune mediated beta cell destruction that leads to absolute insulin deficiency(2). Type 2 DM implies gradual loss of beta cell activity resulting in relative insulin deficieny(2). Hyperglycaemia is the classical clinical manifestation in both types that is mainly linked with an increased risk of microvascular- and macrovascular complications(3). Microvascular complications such as neuropathy, retinopathy and nephropathy as well as macrovascular complications like stroke, ischaemic heart disease and peripheral vascular disease; are chief contributors of increased morbidity and mortality in this population(4).
According to Interntional Diabetes Federation (IDF) report 2019, ‘‘463 million people (aged 20–79 years) worldwide have DM’’ where type 2 DM accounts for 90%. Furthermore, it is projected that by the year 2045, 700 million people will have DM (5). Based on IDF, the Middle East and North Africa region has a high prevalence of DM, with 55 million people affected(5). Furthermore, it has been reported that the incidence is highest among adults living in low- and middle-income countries, accounting for 79% of all cases (6).
Pakistan is a low middle income country with an estimated 221.7 million population making it the world's sixth most populous country(7). Pakistan ranks fourth among top ten countries with the highest number of DM population aged 20–79 years (5). As per IDF report, Pakistan has 19.4 million people (aged 20–79 years) with DM and it is estimated that by 2045, 37.1 million will have DM moving Pakistan to third place (5). Another study estimates that the current DM prevalence in Pakistan is around 26.9% with type 2 DM accounting for 90% of all cases(8).
The rise in type 2 diabetes in Pakistan is driven by socioeconomic, demographic, environmental and genetic factors with key contributors including growing urbanisation, sedentary lifestyle, unhealthy eating habits and obesity (3). Besides, a poor health care system including inaccessibility to health care centers, inequality in health care services provision, gender disparity and poor socioeconomic conditions with low level education as well as unemployment are aggravating the problem (9).
Type 2 DM due to its growing prevalence has turned into a serious health problem for Pakistan and around the world. If not properly managed, it is posing a substantial risk to morbidity and mortality as a result of devastating health complications(10). On the other hand, it is increasing the financial burden of individuals and their families with significant impact on the health systems and national economies (11). Currently, Pakistan is spending 12% of its total health budget (less than 1% of gross domestic product) on DM care with nearly 70% devoted to the management of DM associated complications (9). Therefore, delaying the progression of DM and avoiding its associated complications is the cornerstone that can lead to improved health and economic outcomes of individuals, families, society and the health care system (12).
According to established guidelines, a healthy lifestyle with improvement in self-care behaviours and medication as needed; can delay type 2 DM progression and thus, avoivd serious complications(13). As a result, type 2 DM, is also known as a self-managed condition because patient themselves perform majority of their care(14). Effective self management requires patient’s full commitment and capability to perform self-care activities such as healthy dietary habits, daily physical activity, smoking cessation, regular blood glucose monitoring and regular intake of medicines (12). Patient needs to make a concerted and self motivated effort towards adoption of a healthy life style as pharmacotherapy alone cannot achieve these goals(15). Therefore, for effective self management of type 2 DM; a patient-centered approach is certainly needed.
Patient-centered care has been acknowledged as a desirable attribute of health care since late 1980s when the concept ‘patient centeredness’ was first introduced(16). Patient centeredness refers to the use of a bio-psycho-social perspective which means focusing on the patient and honoring his/her preferences, needs and values as a holistic being rather than a biomedical perspective which focuses on disease(17). Patient-centered care in type 2 DM self-management is a purposefully designed holistic care intervention that provides individuals with information and skills they need to effectively self-manage their condition and achieve optimum glycemic control in addition to medication (18). Self-management education is the major component of patient-centered care which according to WHO, provides basis for management of the disease(19). The literature supports that up to 8% of diabetes-assoicated complications can be reduced through proper self-management education(20). Counselling as behavioral intervention is another major component of patient-centred care. The American Association of Diabetes Educators (AADE) suggests to prepare patients for behaviour change by epuipping them with the necessary skills to improve their self-care behaviors. According to AADE, seven parameters of self care behaviors are ‘‘healthy diet, regular blood-sugar monitoring, regular physical activity, medication adherence, resilient coping skills, effective problem-solving and risk-reduction behaviors (21). Literature supports that behavioral interventions focusing these self care activities resulted in improved health outcomes in this population(22, 23). A meta analysis published in 2003 has demonstrated the effectiveness of educational and behavioral interventions in improving glycemic control in patients with type 2 DM (24).
Given the increasing prevalence of type 2 DM in Pakistan and the risk of increased morbidity and mortality, a patient-centred care can play a crucial role in effective self management. Therefore, an updated systematic review of patient-centered care employing educational and behavioral interventions, would give a better understanding of whether this care approach is associated with improved self-care outcomes. This review aimed to assess the effectiveness of patient-centered care for diabetes self-management to improve glycemic control and self-care behaviors in adults with type 2 DM compared with usual care.