title: Implementation of the Chronic Care Model for diabetes type 2 in Indonesia
Creators: name: Gayatri, Aghnaa
Publisher: name: University of Glasgow
Year: 2023

description: Background and aim: Diabetes type 2 is a major public health concern worldwide. The increasing prevalence of diabetes globally requires countries to develop effective and accessible health care systems built around a strong primary care providing generalist care that is comprehensive and person-centred. The Chronic Care Model (CCM) is a well-known framework that originated in the United States of America (USA) and provides a framework for such care for people with diabetes and other long-term conditions (LTCs). Indonesia has recently implemented a universal health coverage scheme that provides a diabetes management model called Prolanis. Its elements are similar to that of the CCM (though no formal reference to the model has been documented) and very few studies have evaluated its implementation. The PhD thesis aims to assess the appropriateness of the current model of diabetes care implemented in Indonesia with the CCM as a model of reference. In order to fulfil the aim of this thesis, the following objectives and research questions were formulated: 1. Systematic Review of primary care diabetes management models related to the CCM and applied in Southeast Asia a. What types of disease management models for diabetes have been tested or implemented in Southeast Asian countries? b. How are disease management models for diabetes implemented in Southeast Asian countries? c. How effective are disease management models for diabetes in Southeast Asian countries? 2. Determine the characteristics of the diabetes population in Indonesia a. what are the characteristics of individuals with and without diabetes? b. What are the characteristics of individuals with diabetes only and individuals with diabetes and comorbidities? c. What is the prevalence of diagnosed physical and mental comorbidities in individuals with diabetes? d. What is the relationship between diabetes and health care utilisation? 3. Explore the experiences of primary care doctors and patients in the implementation of Indonesia’s diabetes management model, Prolanis a. How is Prolanis implemented in different primary care settings in Indonesia? b. What are the factors influencing the implementation of Prolanis? c. What are the perceived effects of implementing Prolanis in diabetes care provision? 4. Using the CCM as a reference model, how does the use of Prolanis in Indonesia address diabetes management, and how appropriate is it for the Indonesian diabetes population? Methods: This thesis comprises of three studies, utilising multiple methods to answer the research aim: a systematic review on diabetes management models implemented in Southeast Asia; and epidemiological study of the population of people with diabetes in Indonesia; and a qualitative study exploring the experiences of primary care doctors and diabetes patients on Indonesia’s diabetes management model. The systematic review was conducted according to the PRISMA guideline. Eligibility screening was conducted on publications gathered from five databases (Medline, Embase, PsycInfo, CINAHL, and Web of Science). The epidemiological study used publicly available data from the Indonesian Family Life Survey wave 5 (IFLS 5). Analysis included multi-stage binary logistic regression analysis. The qualitative study involved in-depth semi-structures interviews with primary care doctors and patients with diabetes regarding their experience with Prolanis. Interviews were recorded and transcribed verbatim and thematic analysis carried out. Key results: The systematic review identified a total of 18 studies, with 15 models of diabetes management studies from Indonesia, Malaysia, Singapore, the Philippines, and Thailand. Only five studies had a control group. Out of these five, only two were RCTs. The findings indicated that the CCM is not widely acknowledged, implemented, or studied in Southeast Asia. Most models of diabetes management in Southeast Asia emphasised self-management support and the involvement of communities. Most studies reported favourable clinical and non-clinical outcomes and several qualitative studies reported improvements in patient’s satisfaction, confidence, and ability to manage their diabetes after implementation of new models of diabetes care. However, quality appraisal concluded that the included studies were of low to moderate quality. Secondary analysis of the IFLS 5 data was conducted on total of 31,866 participants; of these 31,089 participants did not have diagnosed diabetes (97.5%) and 777 (2.5%) had diagnosed type 2 diabetes. The findings revealed that the majority of people with diabetes in Indonesia have at least one comorbidity, mainly hypertension and high cholesterol. Further analysis showed that having diabetes was a strong predictor health care utilisation, however having one or more comorbidities did not reveal an increase of likelihood of health care utilisation compared to those with diabetes only. Health insurance was a stronger predictor of health care utilisation in the diabetes population. A total of 18 primary care doctors and 18 patients were interviewed in the qualitative study. Analysis revealed that the implementation of Prolanis differed substantially between primary care practices. Implementation was greatly influenced by the practice setting and the social context of their patients. Group sessions and the involvement of communities in the delivery of care was seen as the highlight of successful Prolanis implementation. However, several issues were reported including lack of practice resources, fragmented care between primary and secondary care, and the lack of authority of primary care on comorbidities. Conclusion: This thesis has highlighted a number of issues regarding the implementation of the CCM in diabetes management specifically in Indonesian primary care. The findings suggest that the variation of Indonesia’s primary care practices and social contexts contributed greatly to the different ways in which Prolanis was implemented. Different from other evidence from Southeast Asian countries however, Prolanis has been implemented into routine care, making the continuation of the programme more promising. The prevalence of comorbidities in people with diabetes, as well as other LTCs other than diabetes in Indonesia’s population in general, warrants the consideration of the expansion of Prolanis beyond diabetes care. The development of a high-quality primary care system with fully trained generalist doctors working in an integrated multidisciplinary team is essential to provide care that is comprehensive and person-centred.