Decentralized chronic care service delivery for people living with type 1 diabetes in low- and lower-middle income countries: a scoping review

Abstract Objective The objective of this scoping review is to examine the published literature on the organization of type 1 diabetes (T1D) care provision at primary and first-referral, generally district hospital level) facilities in low-and-lower-middle income countries (LLMICs). Methods This scoping review searched eight databases for published literature (2000-2024) describing service delivery for people living with T1D (PLWT1D) in LLMICs at lower-level health facilities, resulting in 46 papers describing 40 studies. Results 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 HbA1c tests. Many studies reported specialized models, with diabetes clinics housed in outpatient departments, chronic care units, or noncommunicable disease (NCD) clinics. Integrated approaches included diabetes care integrated into NCD clinics or chronic care clinics, while nondifferentiated care in outpatient departments was reported in two studies. In one-third of studies, clinic location could not be determined. Clinics were commonly staffed by mid-level providers, with variable reporting on training and mentoring. Patient education was described in most studies. Conclusion 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, HbA1c 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.