Will diabetes care move closer to rural patients in China? Assessing the impact of an educational intervention for type 2 diabetes among patients and health care professionals in rural China

Aim: The overall aim of this PhD thesis was to increase knowledge on the feasibility and impact of an educational intervention to shift the management of type 2 diabetes mellitus from hospitals to primary health care institutions in rural China.

Study population and methods: All four studies were conducted in Jiangsu province. The educational intervention intended to improve collaboration between the hospital and PHC level, which would strengthen the knowledge and management of diabetes among primary care professionals and in turn lead to improved diabetes knowledge and improved fasting blood glucose (FBG) level among patients. Huaiyin, Jingjiang, and Gaochun county were selected from north, middle, and south part of Jiangsu Province, respectively. The intervention for health care professionals in the intervention areas consisted of three main components: team communication, regular meetings, and professional skills training sessions. Health care professionals in the control group continued with their routine work and had no extra intervention. Patient participants in the intervention areas received services, including health education lectures, periodical follow-up interviews with an annual physical examination, and special medical services. Patients in the control areas received routine services as usual. Baseline data were collected in November 2015, the two follow-up data collections were in October 2016 and July 2017, respectively. Questionnaires were used for patient participants and staff. Study I and Study II evaluated the one-year impact on the patients’ diabetes knowledge, FBG level, and health-related quality of life (HRQoL). Study III concentrated on the impact among health care professionals in PHC institutions for one year. Study IV assessed the two-year impact on diabetes knowledge and FBG level, among patients in the intervention and control group.

Results: The educational intervention had a positive impact in improving diabetes knowledge, lowering FBG levels and improving HRQoL among patients with T2DM at one-year follow-up. A long-term (two years) positive impact was also found on diabetes knowledge and FBG level. The intervention had a differential impact on FBG level for patients in different counties, both at the first and second follow-up, and a two-year positive impact was found only in Gaochun county. The impact was also greater among certain patient groups, especially among females, married persons, low educated persons, and those in farming or house working. Moreover, the intervention had a positive impact among health care professionals in PHC on their professional diabetes knowledge, attitudes and practices regarding the intervention, and types of services they were able to provide.

Conclusions: The educational intervention, with improved collaboration between county hospitals and PHC institutions, and health education to patients, resulted in improved diabetes knowledge and FBG levels and improved some aspects of HRQoL among patient participants. The impact of the intervention was greater among certain patient groups and differed between the counties. The intervention had a positive impact among health care professionals in PHC on their professional diabetes skills, knowledge, attitudes, practices, and types of services they were able to provide. Improved collaboration between county-level hospitals and PHC, with educational efforts both to health care staff and patients with T2DM, appears to be a feasible and effective way of improving care of patients with T2DM in rural areas in China.

List of scientific papers

I. Chen S, Burström B, Sparring V, Qian D, Burström K. Differential impact of an education-based intervention for patients with type 2 diabetes mellitus in rural China. Int J Environ Res Public Health. 2019;16(15):2676.
https://doi.org/10.3390/ijerph16152676

II. Chen S, Qian D, Burström K, Burström B. Impact of an educational intervention in primary care on fasting blood glucose levels and diabetes knowledge among patients with type 2 diabetes mellitus in rural China. Patient Educ Couns. 2020;103(9):1767−1773.
https://doi.org/10.1016/j.pec.2020.03.010

III. Chen S, Qian D, Burström B. Shifting the care of type 2 diabetes mellitus from hospital to primary health care institutions through an educational intervention for health care professionals: An example from rural China. Int J Environ Res Public Health. 2020;17(6):2076.
https://doi.org/10.3390/ijerph17062076

IV. Chen S, Qian D, Burström B. Two-year impact of an educational intervention in primary care on blood glucose control and diabetes knowledge among patients with type 2 diabetes mellitus: A study in rural China. [Submitted]