Adapting chronic care models for diabetes care delivery in low-and-middle-income countries: A review

Table 1 Key contextual factors that is expected to affect chronic care model adaptations for the development of a service delivery model for chronic conditions including type 2 diabetes mellitus

Key factors	Analysis based on context
Community-related
Policy	No specific policies on chronic care delivery exist at both national and local levels
Politics	Informal interviews with government officials suggested some awareness of chronic conditions such as DM type 2 and the needs that must be addressed for the care of chronic conditions in general and DM type 2 in particular in the political environment
Support	National support is limited mostly to prevention and one-day health promotion campaigns on specific chronic conditions
	Support from private organizations and civil societies is currently untapped
Awareness	Informal interviews with local government officials and community members suggested a low level of awareness of DM type 2, the care for DM type 2 and other associated factors, and the prevalence and burden of DM type 2 in the locality
Patient-related
Support	Informal interview with healthcare staff and people with diabetes gave an impression of low level of support given to people with diabetes by the community and health services
Awareness	Informal interview with healthcare staff and people with diabetes gave an impression of low level of knowledge on the condition and care for the condition
Perceived need	Informal interview with people with diabetes revealed a moderate level of perceived need to improve care delivery for their condition
Perceived benefits	Informal interview with people with diabetes revealed a moderate level of perceived benefits of improving care delivery for their condition
Self-efficacy	Informal interview with healthcare staff and people with diabetes suggested a low level of self-efficacy in managing the condition
Provider-related
Perceived need	Informal interview with healthcare staff revealed a high level of perceived need to improve primary care for chronic conditions
Perceived benefits	Informal interview with healthcare staff revealed a high level of perceived benefits of delivering good quality chronic care
Self-efficacy	Informal interview with healthcare staff suggested an impression of low level of self-efficacy in the provision of good quality chronic/diabetes care
Skill proficiency	Informal interview with healthcare staff suggested an impression of a need for skills and knowledge development regarding delivery of good quality chronic/diabetes care
Health service-related
Leadership	The (local) government leaders and health officers are supportive of project implementation
Shared vision	The health system has a shared vision in improving the quality of care for chronic conditions
Organizational norms regarding change	The healthcare workers may be open to small, incremental changes as long as these do not lead to a drastic increase in demands on resources and workload
Administrative support	Administrative support for the project is limited

DM: Diabetes mellitus.

Table 2 Contextual analysis of key factors affecting adaptation of chronic care models and subsequent selection of CACCM elements for implementation making use of Oliver’s typology and characteristics enumerated by Greenhalgh et al[18]

CACCM- and project-related
Oliver’s dimensions
Social legitimacy	Improving care for chronic conditions and protection and promotion of the health and wellbeing of the LGU population enhances the social fitness of the LGHU and the local government
Economic efficiency	The introduction of additional activities in any organization entails additional expenses. Cost-effective or cost-saving innovations would be preferred
External dependence on institutional constituents	The LGHU are dependent on the LGU for funding; the LGU officials who decide on the allocation of these resources are dependent on the populace for their seats in office
Consistency with organizational goals	The primary goal of the LGHU is to provide good quality healthcare to the people
Discretionary constraints imposed on the organization	The LGHU expects full autonomy especially in substantive decision-making such as resource-allocation, resource acquisition, organizational administration, etc.
Voluntary diffusion of norms	A moderate to high degree of voluntary diffusion with some degree of pressure from the LGU officials to diffuse said norms may be most effective in promoting adoption of the intervention
Environmental interconnectedness	A certain degree of predictability of the environment is seen: the general population, especially the people with diabetes and their families will most likely appreciate the intervention. Such appreciation may be reflected on goodwill towards the LGU officials and consequently to the LGHU (for example additional budget allocated to health)
Greenhalgh’s characteristics
Relative advantage	Implementing a diabetes-care project gives the advantage of improving the care for this condition and a number of its comorbidities, but without reduction of other health benefits
Compatibility	Compatibility of the intervention with current/pre-existing activities in the LGHU and with the current duties, responsibilities and workload of the LGHU staff is sought
Simplicity	Simplicity and ease of use of the intervention favors adoption of the intervention
Trialability	Flexibility in accomplishing a number of tasks, i.e., giving leeway to the healthcare staff regarding performance of activities related to the intervention will increase acceptability of the intervention
Observability	Providing information to the intended adopters of the benefits of the intervention, e.g., improvements of glycemia, favors adoption of the intervention
Reinvention	Flexibility of the intervention allowing adaptation and refinement to suit the context, the needs of the individual person with diabetes and the capabilities of the healthcare provider favors its adoption
Risk	Based on outcomes of previous studies conducted on implementation of chronic care models and provision of self-management education, it is certain that the benefits far outweigh the risks
Task issues	Workable and easy to use interventions favor adoption Relevance of the intervention to the work of the staff and tasks that may contribute to the relevance of the work of the individual health care worker is preferred However, the intervention may also be interpreted as an added workload to the LGHU staff
Knowledge required	Knowledge and skills required for full implementation of the intervention need to be supplied/supplemented
Augmentation/support	Provision of a training workshop prior to implementation increases the probability of adoption of the intervention

LGHU: Local government health units; LGU: Local government units.