A scalable solution for delivery of Diabetes Self-Management Education in Thailand

在泰国，2型糖尿病是一个主要的健康问题，2015年有400多万成年人患有这种慢性病。如果疾病处理不当，可能会导致严重的并发症(如心脏病、肾脏疾病、失明)，甚至死亡。此外，泰国经济成本高昂-治疗糖尿病及其并发症消耗了所有医疗支出的10%以上，许多糖尿病患者因此不得不停止工作。为了成功地管理糖尿病并预防其负面后果，教育和生活方式咨询在许多国家被规定为标准，并得到研究证据的支持。这类项目(称为糖尿病自我管理教育，DSME)通过给予人们动力和技能来帮助他们，让他们过上更健康的生活方式，监测并发症的警告信号，遵循复杂的药物治疗方案，并管理糖尿病的压力。在泰国，国家卫生系统目前没有为糖尿病患者提供任何DSME服务，这意味着糖尿病管理不善，并发症发生率高。造成这种服务差距的部分原因是缺乏在泰国被证明有效的DSME计划，但也是政府对在国家层面提供此类计划的负担能力和可行性的担忧。为了克服这些障碍，我们建议为泰国的糖尿病患者开发一个新的低成本DSME计划，在试验中测试它的效果，并了解如何使政府能够负担得起向每个人提供该计划。DSME计划将以每月会议的形式进行，由社区卫生志愿者和护士领导，并辅之以一部关于糖尿病生活的短片，以介绍关键主题。这些电影将在泰国制作，以真实的患者为主角，与获奖的慈善机构医疗援助电影公司(www.Medicalaidfils.org)合作。在教育和技能培训之后，将举行公开讨论会议，讨论共同的挑战和解决方案，设定生活方式目标，并寻求建议。我们将通过与医疗保健工作者和患者团体密切合作，测试我们的初始版本并在观察哪些有效和哪些无效的基础上，制定DSME计划的内容。然后，我们将在试验中测试其有效性，随机分配15家社区医院为所有新诊断的患者提供a)由社区卫生志愿者提供的DSME计划，b)由护士提供的DSME计划，或c)常规护理(不提供DSME计划)。一年后，我们将比较有无DSME计划的医院患者的血糖控制和心脏病风险。我们预测，在接受DSME计划的医院，糖尿病的管理将比没有任何计划的医院更好，护士和社区卫生志愿者都将能够有效地提供这一服务。除了主要试验，我们将收集参与者和卫生保健工作者的数据(通过采访)，了解他们对该计划的反应，以及它为什么以及如何帮助改善糖尿病的管理。了解这些过程对于能够利用从泰国吸取的经验教训，使该计划适应其他国家至关重要。我们将收集与DSME计划每个部分相关的成本数据，并使用它来确定在泰国医疗系统中提供DSME的最负担得起的方式(我们怀疑它将是由社区卫生志愿者提供的DMSE)。我们将把所有这些结果总结成政策建议，供公共卫生部的合作者用来决定是否以及如何向全国提供DSME计划。如果被采纳，该计划将有巨大的潜力改善糖尿病患者的生活，并为泰国的持续经济增长和发展做出贡献。

Type 2 diabetes is a leading health problem in Thailand, with over 4 million adults living with the chronic condition in 2015. If the disease is not managed properly, it can lead to severe complications (e.g. heart disease, kidney disease, loss of sight) and even death. In addition, there are steep costs to the Thai economy - treating diabetes and its complications consumes over 10% of all healthcare spending, and many people with diabetes have to stop work due to the condition. To successfully manage diabetes and prevent its negative consequences, education and lifestyle counselling are prescribed as standard in many countries, supported by research evidence. Such programs (known as Diabetes Self-Management Education, DSME) help people by giving them motivation and skills to lead a healthier lifestyle, monitor warning signs for complications, follow complex medication regimes, and manage the stress of having diabetes. In Thailand, people suffering from diabetes are not currently offered any DSME services by the national health system, which means that management of diabetes is poor and rates of complications are high. The reason for this gap in service is partly the lack of a DSME program proven to work in Thailand, but also government concerns over affordability and feasibility of offering such a program at national level.To overcome these barriers, we propose to develop a new low-cost DSME program for people living with diabetes in Thailand, test that it works in a trial, and also find out how it can be made affordable for the government to provide it to everyone. The DSME program will be delivered as monthly meetings led by community health volunteers and nurses, aided by a short films about living with diabetes, to introduce key topics. These films will be produced in Thailand featuring real patients, in collaboration with award-winning charity Medical Aid Films (www.medicalaidfilms.org). The education and skills training will be followed by an open discussion session to discuss common challenges and solutions, set lifestyle goals and seek advice. We will develop the content of the DSME program through working closely with health care workers and patient groups, testing our initial version and refining it, based on observing what works and what doesn't work. Then we will test its effectiveness in a trial, by randomly assigning 15 community hospitals to offer all newly diagnosed persons either a) DSME program delivered by community health volunteers, b) DSME program delivered by nurses, or c) usual care (no DSME program). After one year, we will compare the control of blood glucose and risk of heart disease between patients of hospitals with and without the DSME program. We predict that in hospitals receiving the DSME program, management of diabetes will be better than in those without any program, and that both nurses and community health volunteers will be able to deliver it effectively. Alongside the main trial, we will collect data from participants and health care workers (through interviews) on their responses to the program and why and how it helped to improve diabetes management. Understanding these processes is vital to be able to adapt the program for other countries, making use of lessons learnt in Thailand. We will collect data on the costs involved with each part of the DSME program, and use it to identify the most affordable way of providing DSME in the Thai health system (we suspect it will be DMSE provided by community health volunteers). We will summarize all these results into policy recommendations, to be used by our collaborators at the Ministry of Public Health to decide whether and how to deliver the DSME program to the whole country. If adopted, the program has huge potential to improve the lives of people with diabetes and contribute to Thailand's continued economic growth and development.