Implementation strategies for evidence-based management of type 2 diabetes at primary healthcare facilities in low- and middle-income countries and related barriers and facilitators: a scoping review.

Abstract

Background: Type 2 Diabetes prevalence is rapidly increasing in low- and middle-income countries (LMICs), where constrained health budgets and inequitable resource distribution limit access to quality care. Primary healthcare is central to addressing these challenges; however, the implementation of evidence-based diabetes care remains inconsistent. This scoping review mapped implementation strategies for integrating diabetes care into primary healthcare settings in LMICs and identified associated barriers and facilitators influencing implementation.

Methods: This review focuses on type 2 diabetes, given its predominance and relevance to primary healthcare delivery in LMICs, and followed the Joanna Briggs Institute methodology for scoping reviews and was reported in accordance with PRISMA-ScR guidelines. The search strategy was peer-reviewed using the PRESS checklist. Eight electronic databases were searched for studies published between January 1996 and November 2024. Eligible studies were conducted in LMICs, as defined by the World Bank, and described the implementation, adaptation, or evaluation of evidence-based Type 2 diabetes care in primary healthcare settings. Two reviewers independently screened titles, abstracts, and full texts. Implementation strategies were mapped to the Expert Recommendations for Implementing Change (ERIC) taxonomy, while reported barriers and facilitators were coded using the Consolidated Framework for Implementation Research (CFIR).

Results: Ninety-two articles describing 85 studies across 27 LMICs were included. Implementation strategies most frequently clustered within Engage Consumers, Change Infrastructure, and Use Evaluative and Iterative Strategies, whereas Adapt and Tailor to Context and Utilise Financial Strategies were less often explicitly reported. Forty-three studies reported clinical outcomes only, 11 reported implementation outcomes only, and 31 reported both. Studies more frequently reported improvements in clinical and/or implementation outcomes that combined multiple strategies, particularly provider training and decision support alongside patient or family engagement and pragmatic system redesign. Co-occurrence analyses indicated that Train and Educate Stakeholders was frequently paired with Engage Consumers, supported by supervision, feedback mechanisms, and infrastructure strengthening. CFIR mapping suggested that workflow integration, leadership engagement, regular supervision, and reliable medicine and diagnostic supplies were commonly associated with improved adoption and fidelity, while connectivity challenges, stock-outs, and high workload disrupted implementation and limited scale-up. Reporting of adoption, fidelity, and acceptability remained uneven, and financial strategies were poorly described despite their relevance to sustainability.

Conclusion: In LMIC primary healthcare settings, diabetes care implementation most commonly emphasises provider training, infrastructure strengthening, and interactive support strategies, while explicit attention to contextual adaptation and financial mechanisms is less frequently reported. Implementation outcomes were reported to be influenced by leadership engagement, digital tools, and community involvement, alongside persistent constraints related to workforce capacity, supply chains, and feedback systems. Future implementation efforts should more explicitly address contextual fit, system integration, and sustainability when designing and scaling diabetes care interventions in primary healthcare.