A Thematic Analysis of Non-Pharmacological Intervention Strategies in the Management of Diabetic Patients in Malaysia

Pharmacotherapy is one of the most effective treatments for the control of diabetes and the prevention of its complications. Optimal glycaemic control can reduce the healthcare burden. Nonetheless, the efficacy of diabetes management is often limited by poor medication adherence among patients. The level of medication adherence among diabetic patients in Malaysia has been reported to be 36%-87% for oral medication and 54%-81% for insulin injection. In order to increase the proportion of diabetic patients with good glycaemic control and low disease complications, other intervention strategies that are complementary to drug treatment should be considered. These strategies include all the non-pharmacological interventions and patient-mediated strategies that can be implemented either as standalone or adjunct therapy to promote better diabetic control among patients who are already prescribed with conventional pharmacotherapy. This study aimed to provide a synthesis of the themes for all the non-pharmacological intervention strategies applied in the management of diabetic patients in Malaysia. An electronic literature search for English articles in four databases (PubMed, SCOPUS, Web of Science, and OVID) was conducted using relevant search strings. Twenty-two articles were included in the final analysis. Six themes were identified, namely diabetes education programmes, patient empowerment programmes, adherence support programmes, lifestyle adjustment programmes, psychological intervention programmes, and shared decision- making. Further research is warranted to empirically validate these results and to obtain a better understanding of the themes that are most meaningful for patients as well as their practical application in real-life settings.

1.        Ali MK, Siegel KR, Chandrasekar E, Tandon N, Montoya PA, Mbanya JC, et al. Diabetes: An Update on the Pandemic and Potential Solutions. In: Disease Control Priorities, Third Edition (Volume 5): Cardiovascular, Respiratory, and Related Disorders. 2017.

2.        Ghaffar A, Reddy KS, Singhi M. Burden of non-communicable diseases in South Asia. BMJ. 2004;328(7443):807-10.

3.        Pan WH, Yeh WT, Hwu CM, Ho LT. Undiagnosed diabetes mellitus in Taiwanese subjects with impaired fasting glycemia: impact of female sex, central obesity, and short stature. Chin J Physiol. 2001;44(1):44-51.

4.        Feisul I. Current burden of diabetes in Malaysia. In: 1st National Institutes of Health (NIH) Scientific Meeting. 2012.

5.        Mafauzy M, Hussein Z, Chan SP. The status of diabetes control in Malaysia: results of DiabCare 2008. Med J Malaysia. 2011;66(3):175-81.

6.        Institute for Public Health. National Health and Morbidity Survey (NHMS) 2019: Non-communicable diseases, healthcare demand, and health literacy—Key Findings. Institute for Public Health; 2020.

7.        Leite RG, Banzato LR, Galendi JS, Mendes AL, Bolfi F, Veroniki AA, et al. Effectiveness of non-pharmacological strategies in the management of type 2 diabetes in primary care: a protocol for a systematic review and network meta-analysis. BMJ Open. 2020;10(1):e034481.

8.        Presley B, Groot W, Pavlova M. Pharmacy-led interventions to improve medication adherence among adults with diabetes: A systematic review and meta-analysis. United States: Elsevier Inc.; 2019.

9.        Odgers‐Jewell K, Ball LE, Kelly JT, Isenring EA, Reidlinger DP, Thomas R. Effectiveness of group‐based self‐management education for individuals with Type 2 diabetes: a systematic review with meta‐analyses and meta‐regression. Diabet Med. 2017;34(8):1027-39.

10.      Chew BH, Vos RC, Metzendorf MI, Scholten RJ, Rutten GE. Psychological interventions for diabetes‐related distress in adults with type 2 diabetes mellitus. Cochrane Database Syst Rev. 2017(9).

11.      Ismail M, Teng CL, Omar M, Ho BK, Kusiar Z, Hasim R. Usage of glucometer is associated with improved glycaemic control in type 2 diabetes mellitus patients in Malaysian public primary care clinics: an open-label, randomised controlled trial. Singapore Med J. 2013;54(7):391-5.

12.      Ibrahim N, Ming Moy F, Awalludin IA, Mohd Ali Z, Ismail IS. Effects of a community-based healthy lifestyle intervention program (co-HELP) among adults with prediabetes in a developing country: a quasi-experimental study. PloS One. 2016;11(12):e0167123.

13.      Ramli AS, Selvarajah S, Daud MH, Haniff J, Abdul-Razak S, Tg-Abu-Bakar-Sidik TM, et al. Effectiveness of the EMPOWER-PAR intervention in improving clinical outcomes of type 2 diabetes mellitus in primary care: a pragmatic cluster randomised controlled trial. BMC Fam Pract. 2016;17(1):1-18.

14.      Chew BH, Vos RC, Fernandez A, Shariff Ghazali S, Shamsuddin NH, Ismail M, et al. The effectiveness of an emotion-focused educational programme in reducing diabetes distress in adults with type 2 diabetes mellitus at 12-month follow-up: a cluster randomized controlled trial. Ther Adv Endocrinol Metab. 2019;10:2042018819853761.

15.      Lee JY, Chan CK, Chua SS, Ng CJ, Paraidathathu T, Lee KK, et al. Telemonitoring and team-based management of glycemic control on people with type 2 diabetes: a cluster-randomized controlled trial. J General Intern Med. 2020;35(1):87-94.

16.      Wong SS, Ng CJ, Liew SM, Hussein N. Effectiveness of a colour coded HbA1c graphical record in improving diabetes control in people with type 2 diabetes: a randomized control trial. Diabetes Res Clin Pract. 2012;95(2):e41-4.

17.      Ahmad B, Ramadas A, Kia Fatt Q, Zain AZ. A pilot study: the development of a culturally tailored Malaysian Diabetes Education Module (MY-DEMO) based on the Health Belief Model. BMC Endocr Disord. 2014;14(1):1-8.

18.      Lee YK, Lee PY, Ng CJ, Teo CH, Abu Bakar AI, Abdullah KL, et al. Usability and utility evaluation of the web-based “Should I Start Insulin?” patient decision aid for patients with type 2 diabetes among older people. Inform Health Soc Care. 2018;43(1):73-83.

19.      Ramadas A, Chan CK, Oldenburg B, Hussein Z, Quek KF. Randomised-controlled trial of a web-based dietary intervention for patients with type 2 diabetes: changes in health cognitions and glycemic control. BMC Public Health. 2018;18(1):1-3.

20.      Lee JY, Chan CK, Chua SS, Ng CJ, Paraidathathu T, Lee KK, et al. Intervention for Diabetes with Education, Advancement and Support (IDEAS) study: protocol for a cluster randomised controlled trial. BMC health Serv Res. 2016;16(1):1-9.

21.      Sharoni SK, Rahman HA, Minhat HS, Ghazali SS, Ong MH. A self-efficacy education programme on foot self-care behaviour among older patients with diabetes in a public long-term care institution, Malaysia: a Quasi-experimental Pilot Study. BMJ Open. 2017;7(6):e014393.

22.      Wasif Gillani S. Determining effective diabetic care; a multicentre-longitudinal interventional study. Curr Pharm Des. 2016;22(42):6469-76.

23.      Chow EP, Hassali MA, Saleem F, Aljadhey H. Effects of pharmacist-led patient education on diabetes-related knowledge and medication adherence: A home-based study. Health Educ J. 2016;75(4):421-33.

24.      Lim PC, Lim K. Evaluation of a pharmacist-managed diabetes medication therapy adherence clinic. Pharm Pract. 2010;8(4):250.

25.      Butt M, Ali AM, Bakry MM, Mustafa N. Impact of a pharmacist led diabetes mellitus intervention on HbA1c, medication adherence and quality of life: A randomised controlled study. Saudi Pharm J. 2016;24(1):40-8.

26.      Bakar ZA, Fahrni ML, Khan TM. Patient satisfaction and medication adherence assessment amongst patients at the diabetes medication therapy adherence clinic. Diabetes Metab Syndr. 2016;10(2):S139-43.

27.      Ayadurai S, Sunderland VB, Tee LBG, Md Said SN, Hattingh HL. Structured tool to improve clinical outcomes of type 2 diabetes mellitus patients: A randomized controlled trial. J Diabetes. 2018;10(12):965-76.

28.      Lim PC, Lim K, Embee ZC, Hassali MA, Thiagarajan A, Khan TM. Study investigating the impact of pharmacist involvement on the outcomes of diabetes medication therapy adherence program Malaysia. Pak J Pharm Sci. 2016;29(2).

29.      Ahmad B, Zain AZ, Fatt QK. Type 2 diabetes patients are more amenable to change following a contextualised diabetes education programme in Malaysia. Diabetes Metab Syndr. 2017;11:S901-6.

30.      Tan MY, Magarey JM, Chee SS, Lee LF, Tan MH. A brief structured education programme enhances self-care practices and improves glycaemic control in Malaysians with poorly controlled diabetes. Health Educ Res. 2011;26(5):896-907.

31.      Sazlina SG, Browning CJ, Yasin S. Effectiveness of Personalized Feedback Alone or Combined with Peer Support to Improve Physical Activity in Sedentary Older Malays with Type 2 Diabetes: A Randomized Controlled Trial. Front Public Health. 2015;3:178.

32.      Alvani SR, Zaharim NM, Wynne Kimura L. Effect of group cognitive behavioral therapy (CBT) on psychological well-being and glycemic control in adults with type 2 diabetes. Int J Diabetes Dev Ctries. 2015;35(2):284-9.

33.      Chew BH, Vos RC, Shariff Ghazali S, Shamsuddin NH, Fernandez A, Mukhtar F, et al. The effectiveness of a value-based EMOtion-cognition-Focused educatIonal programme to reduce diabetes-related distress in Malay adults with Type 2 diabetes (VEMOFIT): study protocol for a cluster randomised controlled trial. BMC Endocr Disord. 2017;17(1):1-3.

34.      Ministry of Health Malaysia. Clinical Practice Guidelines (CPG) on Management of Type 2 Diabetes Mellitus. Igarss 2014. 2015.

35.      Chatterjee S, Davies MJ, Heller S, Speight J, Snoek FJ, Khunti K. Diabetes structured self-management education programmes: a narrative review and current innovations. Lancet Diabetes Endocrinol. 2018;6(2):130-42.

36.      Abbasi YF, See OG, Ping NY, Balasubramanian GP, Hoon YC, Paruchuri S. Diabetes knowledge, attitude, and practice among type 2 diabetes mellitus patients in Kuala Muda District, Malaysia–A cross-sectional study. Diabet Metab Syndr. 2018;12(6):1057-63.

37.      Li LC, Swee WC, Arasu K, Kim KS, Ali SZ. Diabetes literacy and knowledge among patients with type 2 diabetes mellitus attending a primary care clinic in Seremban, Malaysia. Malays J Nutr. 2019;25(3):435-44.

38.      Loveman E, Frampton GK, Clegg AJ. The clinical effectiveness of diabetes education models for Type 2 diabetes: a systematic review. Health Technol Assess. 2008;12(9):1-36.

39.      Pillay J, Armstrong MJ, Butalia S, Donovan LE, Sigal RJ, Chordiya P, et al. Behavioral programs for type 1 diabetes mellitus: A systematic review and meta-Analysis. Ann Intern Med. 2015;163(11):836-47.

40.      Pillay J, Armstrong MJ, Butalia S, Donovan LE, Sigal RJ, Chordiya P, et al. Behavioral programs for type 2 diabetes mellitus: A systematic review and network meta-Analysis. Ann Intern Med. 2015;163(11):848-60.

41.      Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient Educ Couns. 2016;99(6):926-43.

42.      Norris SL, Nichols PJ, Caspersen CJ, Glasgow RE, Engelgau MM, Jack Jr L, et al. Increasing diabetes self-management education in community settings: a systematic review. Am J Prev Med. 2002;22(4):39-66.

43.      Lelubre M, Kamal S, Genre N, Celio J, Gorgerat S, Hugentobler Hampai D, et al. Interdisciplinary medication adherence program: the example of a university community pharmacy in Switzerland. BioMed Res Int. 2015;2015:103546.

44.      Liu Y, Meng LL, Li JW, Jin YS, An RH. A Randomized Study on the Effect of Metformin Combined with Intensive-Exercise Diet Therapy on Glucose and Lipid Metabolism and Islet Function in Patients with Renal Cell Carcinoma and Diabetes. Dis Markers. 2022;2022:7383745.

45.      Egger G, Dixon J. Beyond obesity and lifestyle: a review of 21st century chronic disease determinants. Biomed Res Int. 2014;2014:731685.

46.      Uchino BN. Social support and physical health: Understanding the health consequences of relationships. New Haven, CT, US: Yale University Press; 2004.

47.      Riemsma RP, Pattenden J, Bridle C, Sowden AJ, Mather L, Watt IS, et al. A systematic review of the effectiveness of interventions based on a stages-of-change approach to promote individual behaviour change. Health Technol Assess. 2002;6:1-231.

48.      Carreira-Míguez M, Ramos-Campo DJ, Clemente-Suárez VJ. Differences in Nutritional and Psychological Habits in Hypertension Patients. Biomed Res Int. 2022;2022:1920996.

49.      Murray E, Charles C, Gafni A. Shared decision-making in primary care: tailoring the Charles et al. model to fit the context of general practice. Patient Educ Couns. 2006;62(2):205-11.

50.      Barry MJ. Shared decision making: informing and involving patients to do the right thing in health care. J Ambul Care Manage. 2012;35(2):90-8.