Development of self-management program with carbohydrate counting for Type 1 Diabetes delivered during Covid-19 pandemic

ABSTRACT

Background: There is a lack of data on effectiveness of diabetes self-management education and support (DSMES) programs for South Asian adults with type 1 diabetes mellitus (T1DM). Aim: This formative research was conducted to explore existing practices on the said subject and gather information for planning an enhanced usual care (EUC) intervention program. The suggestions were incorporated for the intervention to be delivered especially during Covid-19. Method: We conducted in-depth semi-structured interviews with endocrinologists, dieticians, diabetes educators and adults with T1DM for this qualitative formative research. The participants were selected from a mix of public and private health facilities. Thematic analysis using inductive and deductive approach was undertaken. Results: In total, 28 in-depth interviews were conducted, 18 with health care professionals and 10 with adult individuals with T1DM. The results demonstrated deficiencies in the implementation of a structured self-management program for diabetes owing to several patient and healthcare system-related factors in usual practice. A detailed nutritional counselling was provided at all sites by a qualified dietitian, however, carbohydrate counting was not routinely practiced. The content of this formative research revolved around two broad domains hence explored (a) evaluation of the existing usual care and gaps in implementation of a structured DSMES program, and (b) development of approaches that will help in formulation of an intervention package and its effective delivery to the participants. Principles of FUSED and COM-B models were also reported to be significant components for the success and refinement of such interventions. During the pandemic, the challenges reported in diabetes management were in maintaining monitoring chart of blood glucose levels due to lack of monitoring strips, procurement of insulin, procurement of diabetes supplies and management of disease condition during acute complications with lack of hospital facilities. Blood sampling was reported to be halted due to complete lockdown and restricted red zones. For effective delivery of such EUC interventions, it was suggested to conduct the sessions via video conferencing apps. Similarly, the follow-ups and reinforcement during this period were suggested to continue via telephonic calls, audio clips, video calls, video clips and SMS modes. As a part, it was suggested to relax blood glucose monitoring, the insulin of same type but different brands were suggested to be prescribed among choices available in local area and other mentioned challenges were suggested to be continuously looked after and provide timely advice for the same emphasizing sick day rules. Further, it was suggested to get the blood tests performed from reliable (accredited) labs at the recommended intervals. Discussion: This research study comprehensively investigated the existing practices among diabetes-health care professionals caring for persons living with T1DM, deficiencies in carbohydrate counting meal-planning technique and rendered insights towards development of a scientific DSMES program.