The length of intervention strategies reported in the included studies ranged between 3 and 18 months. The interventions included as low as one and up to eight follow-up sessions. The interventions could be delivered by pharmacists, physicians, nurses, psychological therapists, or a multi-disciplinary team. Five interventions were provided by a team of two healthcare providers or more [11-15], whereas four studies did not mention the healthcare provider delivering the interventions [16-19]. Most studies (n=20) reported the effects of non-pharmacological intervention strategies on multifaceted outcomes. Most studies (n = 17) reported glycaemic control as the primary or secondary outcome. In addition, the studies also measured other outcomes such as blood pressure, lipids profile, body weight, psychological measures, knowledge, retention rate, self-care, foot condition, and quality of life. Two pilot studies [17, 18] aimed to determine their proposed interventions' applicability and utility. Lastly, one was a protocol for an RCT of education and support on managing diabetic patients [20].

Themes of Interventions

The included studies varied regarding the intervention strategy, duration, and providers based on the results. Most intervention strategies focus on increasing patients' knowledge and self-efficacy. Six intervention strategies were found, namely diabetes education [12-14, 17, 18, 20-29], patient empowerment [11-13, 15-17, 20-23, 25, 26, 29, 30], adherence support [15, 23-28], lifestyle adjustment [12, 19, 23, 25, 27, 31], psychological intervention [12, 19, 20, 31-33], and shared decision-making [18]. Most of the studies combined different intervention strategies in their services. Figure 2 shows a network view on the themes of non-pharmacological interventions applied in managing diabetic patients.

Diabetes Education Activities

This review aimed to identify the intervention strategies applied in managing diabetic patients in Malaysia. The most commonly provided intervention strategies included diabetes education modules and patient empowerment. Other strategies used to a certain degree included adherence support, lifestyle adjustment activities, psychological interventions, and shared decision-making. The interventions were carried out in outpatient settings, in the community or patient's home.

Among the 22 included studies, diabetes education programs were conducted in 16 of them either as a single intervention or in combination with other non-pharmacological intervention strategies. However, the specific contents of the modules differ from one study to another based on the objectives and the providers of the studies. For example, an education module provided by dieticians focused more on diet-related information while those by pharmacists emphasized medication adherence. However, all the modules incorporated a basic diabetes education module that included information on diet, exercise, medication, complications, and self-care as recommended by the local clinical practice guideline [34]. As the latest innovation in diabetes structured education programs, the diabetes education model was the most commonly incorporated intervention strategy in non-pharmacological diabetes management [35].

Recently, a few studies in Malaysia showed that the low level of diabetes knowledge among diabetic patients could be correlated with their education level and ethnicity [36, 37]. Therefore, diabetes education programs should be tailored to the population's specific needs. The effectiveness of multi-component diabetes education programs is highly dependent on the multi-professional team involved in the service provision [38]. In the Malaysian public setting, diabetic patients visit several health professionals throughout their treatment and follow-up. As a result, the patient may lose interest in the program when they are repeatedly fed with redundant information. Thus, it is vital to design and implement a single education program via the collaboration of multi-disciplinary professionals to ensure the program's success.

Patient Empowerment Activities

In diabetes, self-management is a concept that has been long discussed since 1970. Systematic reviews showed that diabetes self-management education could improve glycaemic control in type 1 [39] and type 2 diabetes [40, 41]. Patient empowerment can be developed by providing proper self-management education and activities to help patients manage their disease effectively. In the current review, 14 studies used patient empowerment as one of the interventions, either alone or in combination with other strategies. Six studies provided the intervention through group activities [12, 14, 17, 20, 21, 32] in which patients underwent interactive sessions and received lectures by trained facilitators in small groups. Patients with chronic diseases tend to have difficulties coping with their conditions, and group activities offer them the opportunity to receive emotional support from others who experience similar conditions. The delivery of patient empowerment activities through group activities is associated with great potential to improve metabolic control [42].

Apart from that, patient empowerment activities can also be provided via computer and mobile applications. However, only one study in Malaysia reported on the utilization of self-management activities that incorporated a technology-enabled self-management feedback loop to connect diabetic patients with their healthcare team. The study by Chow Ee Pin (2015) may serve as a reference for future self-management programs in Malaysia that incorporate multiple self-management components with technology-enabled interventions and individualized feedback [23].

Adherence Support Activities

Seven of the included studies provided adherence support activities as part of the non-pharmacological management. The pharmacist delivered these activities alone or as part of a multi-disciplinary healthcare team effort. They involved the review of patients' medication-taking behavior and the identification of any non-adherence and reasons for it [43]. The ultimate aim of the activities was to provide the necessary intervention or support to improve patients' adherence to medicines. In Malaysia, such activities were mostly provided through the Medication Therapy Adherence Clinic (MTAC) that the Ministry of Health introduced in 2006. Most of the interventions utilized face-to-face interventions in outpatient settings, for example, at the pharmacy or doctor's clinics. However, the exception was the study by Lee et al. (2020) that applied telehealth as the main mode of service delivery [15]. Nevertheless, telehealth was found to be of limited benefit as a replacement for face-to-face consultation due to the lack of engagement between patients and providers, which is crucial for interpreting the results and decision-making for further management. In the future, a more interactive telehealth module can be designed to address this limitation.

Lifestyle Adjustment Activities

Only one study was found to promote lifestyle changes as part of the diabetes non-pharmacological intervention strategies [31]. It is important to incorporate lifestyle adjustment interventions such as diet modification and physical activities in managing diabetes patients. In the study, the personalized feedback strategies focused on utilizing peer support to enhance improvement in physical activity. Pharmacotherapy combined with exercise and diet therapy had been shown to significantly improves the glucose and lipid metabolism of diabetic patients [44, 45]. Patients receiving support from peers and personalized feedback were found to have better glycaemic control than those who received personalized feedback alone. Since modifications in dietary habits and physical activity may be difficult to achieve without social support, motivation from close ones such as family members and friends can be beneficial in encouraging effective lifestyle changes [46].

Additionally, lifestyle adjustment interventions appeared more effective when tailored based on the patient's readiness to change. Improvement of physical activity levels and healthy eating habits were more prominent in interventions based on the stages-of-change approach [47]. Interestingly, in this review, a study suggested that dietary changes should only be promoted among patients in the pre-contemplation and contemplation stages [19]. This way, the efforts can focus on patients who need the intervention. Therefore, the application of the stages of change should be studied more extensively in the future to deliver interventions other than lifestyle adjustments.

Psychological Intervention Activities

A total of five studies were found to implement several types of psychological interventions such as behavioral modification techniques, cognitive behavior techniques, and motivational interviewing. These interventions aimed to promote behavioral changes that reduce stress and dropout rate in the intervention activities [12, 19, 20, 31, 32]. Patients with chronic diseases are often psychologically- challenged in dealing with the strains of the diseases. For diabetic patients, further stressors are present such as the need to adhere to dietary restraints, perform physical activity and self-monitoring blood glucose, not to mention the regular consumption of oral medications or insulin injection and regular foot care. Psychological interventions usually aim to reduce distress among the patients and ensure the retention rate for other interventions that promote behavioral change. The combination of psychological therapy with pharmacological interventions had been shown to improve disease control [48]. A therapeutic alliance must be formed between the patient and the therapist to bring about changes in emotional, cognitive, and behavioral functioning before subsequently improving patients' adherence. However, the most effective psychological intervention approach and the subgroup of patients most likely to benefit from it have not yet been established.

Shared Decision Making

Only one study included shared decision-making activity in the management [18]. Shared decision-making is a model in which clinicians and patients share the best evidence before reaching a healthcare decision. During the session, information and values of treatments are shared between patients and healthcare professionals. Patients are encouraged to play an active role in making their healthcare decisions [49]. Previous studies showed that shared decision-making improved patients' interpretation of clinical evidence before deciding on treatment choices [50]. It also improved the management outcomes by enhancing patients' commitment to managing their condition, such as improving their medication adherence behavior.

To the best of our knowledge, this thematic analysis of the literature is the first attempt to integrate theoretical and empirical literature on non-pharmacological interventions in managing diabetic patients in Malaysia. The six emerging themes showed the diversity and applicability of various intervention strategies in Malaysia. These themes could be combined to develop a more comprehensive module for managing diabetic patients in Malaysia. This review is another step towards achieving a better understanding of how healthcare providers can apply different intervention strategies in the context of diabetes management. However, further theoretical and empirical work is still needed to expand the construction and support the proposed themes. This study is subjected to a few limitations. Firstly, the probable absence of relevant articles and any unpublished content might be an issue in the comprehensiveness of the review. However, we have taken extensive steps to ensure an exhaustive literature review. The search strategy was adapted for different databases and was developed in collaboration with field experts. Secondly, although it is beyond the scope of this paper, addressing the effectiveness of different types of interventions will broaden the impact of the results and should be considered in future studies.

CONCLUSION

In summary, this article presents a thematic analysis of the literature on non-pharmacological interventions in managing diabetic patients in Malaysia. Six themes were identified, namely diabetes education programs, patient empowerment programs, adherence support programs, lifestyle adjustment programs, psychological intervention programs, and shared decision-making. Further research is needed to empirically validate these results to obtain a better understanding of the most meaningful themes for patients and their applicability in real-life settings.

ACKNOWLEDGMENTS: The authors would like to thank Universiti Kebangsaan Malaysia for funding this project and Ministry of Health Malaysia for providing the PhD scholarship to Fahmi Hassan.

CONFLICT OF INTEREST: None

FINANCIAL SUPPORT: This study received funding from the Research University Grant of Universiti Kebangsaan Malaysia reference number GUP-2021-010.

ETHICS STATEMENT: None