Models of care for children and adolescents with type 1 diabetes in low- and middle-income countries: a scoping review.

Background: 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 methods: 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.