GRAPHICAL ABSTRACT

INTRODUCTION

The increasing prevalence of chronic diseases poses a significant challenge for healthcare systems worldwide. Type 2 diabetes mellitus (T2DM) is one such chronic condition requiring long-term medication management. According to the Survei Kesehatan Indonesia in 2023 [1], 50.2% of diabetes cases in Indonesia are classified as T2DM. This condition impacts multiple aspects of patient life, significantly reducing the quality of life compared to the general population due to the associated physical discomfort and psychological anxiety [2].

Managing T2DM involves addressing several barriers related to treatment adherence. A significant challenge to therapeutic adherence is patient engagement in treatment management. The comprehensive management of T2DM extends beyond pharmacological intervention. According to PERKENI 2021 guidelines [3], T2DM management encompasses dietary modifications, physical exercise, and pharmacological treatment. Education serves as an essential tool for improving patient participation in therapy. Despite a high rate of accessibility to T2DM patient education in Indonesia (81.4%), only 59.2% of patients consistently attend healthcare follow-up visits [1].

Previous studies indicate that educational interventions conducted by healthcare professionals can improve glycemic control. However, there is an ongoing need for effective educational strategies capable of producing sustained improvements in health outcomes. Currently implemented educational programs vary significantly, and while the quality of education provided is diverse, maintaining long-term patient engagement in therapy remains challenging [4]. Therefore, the healthcare system must explore innovative strategies for delivering educational programs to patients with chronic diseases [5,6]. This systematic review evaluates existing literature to identify the most effective educational methods for improving clinical outcomes among the variety of educational models currently implemented.

METHODS

This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Search Strategy

In February 2024, a systematic search was conducted across 3 electronic databases: Science Direct, PubMed, and Scopus. The literature search employed consistent keywords across databases, specifically “type 2 diabetes mellitus,” “education,” “pharmacist,” and “HbA1c.” Search criteria were limited to articles published within the past 10 years, ensuring the retrieval of up-to-date information and minimizing potential biases due to historical contexts differing significantly from the present, even if the information itself remains valid. Only articles available as full-text publications were included.

Inclusion and Exclusion Criteria

The following inclusion criteria were used in the literature search: (1) participants diagnosed with T2DM, (2) interventions involving educational programs, (3) interventions conducted by pharmacists or where pharmacists were among the educational providers, and (4) articles published in English. Exclusion criteria included studies that were not trial research, studies involving participants other than patients with T2DM, or studies limited to specific T2DM patient subgroups (e.g., exclusively T2DM patients with foot ulcers). All retrieved records were exported into Mendeley and duplicates were subsequently removed.

Data Collection and Processing

Two independent reviewers (IM and NMY) assessed article eligibility based on the predetermined inclusion and exclusion criteria, primarily by screening the titles and abstracts. Any disagreements regarding article selection were resolved through discussion with a third reviewer (AWW). The quality assessment of selected studies was performed using the Consolidated Standards of Reporting Trials (CONSORT) 2010 checklist. Studies with or without randomization, control groups, or both were included. Results from the risk-of-bias analysis are summarized in Table 1 [7–23].

Reviewing Selected Studies

A structured data extraction form was employed by IM, AWW, and PS to independently extract data from the full-texts of the selected studies. Extracted details included authors’ names, publication year, country, coexisting conditions in T2DM patients, method of educational delivery, intervention frequency, session length, overall program duration, educational providers involved, content of education, and reported outcomes. Although hemoglobin A1c (HbA1c) was the primary outcome, additional clinical outcomes were also documented. This review systematically summarized and related educational delivery methods to clinical outcomes in T2DM patients.

Ethics Statement

This systematic review did not involve direct human participation and thus did not require ethical approval.

RESULTS

The search identified 105 relevant articles across the databases (PubMed: n=10; Science Direct: n=85; Scopus: n=10). After removing duplicate records and screening titles and abstracts, 30 articles remained for full-text assessment. Following comprehensive screening, 17 articles [7–23] met the inclusion criteria. The PRISMA flowchart illustrating this selection process is presented in Figure 1 [24]. The primary reason for exclusion during title and abstract screening was that the study participants included conditions other than T2DM, or diabetes mellitus appeared only as a comorbidity accompanying another primary diagnosis. Conversely, the main reason for exclusion during full-text screening was the absence of an educational intervention. Numerous trials included T2DM patients with specific circumstances, such as those at risk for cardiovascular disease [7], individuals with hypertension [8], patients receiving only insulin therapy [9,10], and patients treated exclusively with oral medications [11]. The educational content in these studies was consistent with that employed for patients diagnosed exclusively with T2DM.

Due to the nature of the educational intervention, blinding was not feasible in any included study. Eleven studies implemented randomization of respondents [8–10,12–19], whereas non-randomized studies employed purposive sampling methods. Three studies [7,20,21] did not include a control group. Outcome improvements were assessed by comparing pre-intervention and post-intervention findings.

Table 2 [7–23] summarizes the characteristics of the included studies. All studies were published between 2015 and 2024, and involved outpatient settings. Geographically, the studies were distributed across Asia (n=8), America (n=5), Africa (n=2), and Europe (n=2). Many selected studies included specific patient subgroups, such as T2DM patients at increased cardiovascular risk [7], patients undergoing insulin therapy [9,10], those receiving oral medications exclusively [11], and patients with hypertension [8].

All studies evaluated clinical outcomes beyond HbA1c, with a detailed summary of HbA1c changes for each study provided in Table 2 [7–23], which also specifies whether each study included a control group. Clinical outcomes were reported based on the statistical significance of changes rather than numerical data due to variations in analytic approaches across studies. Additionally, many studies assessed humanistic outcomes such as medication adherence [8–10,13,15,16,18,22], self-management or self-care behaviors [11,14,17,23], and quality of life [10,13,19]. Several studies specifically explored aspects of physical activity [7,21] and dietary habits [7]. Two studies utilized quality-adjusted life years [12] and treatment costs [19] as measures of economic outcomes. Only 1 study [20] focused exclusively on clinical outcomes.

Pharmacists served prominently as educators in most selected studies. Five studies [7,12,20,21,23] involved pharmacists as part of multidisciplinary education teams, whereas 2 studies [8,10] specifically featured clinical pharmacists as the primary educators. All studies incorporated face-to-face interactions; however, due to the COVID-19 pandemic, some interventions were delivered online. Several studies explored various educational delivery methods, including podcasts [20], smartphone applications [21], messaging groups [8], group activities [7,19], and telepharmacy follow-ups [16].

The frequency of educational sessions varied widely, ranging from 2 sessions to 16 sessions. The overall duration of educational interventions ranged from 3 months to 3 years, although most programs were completed within 6 months. Program durations were often influenced by recruitment procedures and follow-up intervals. Several studies conducted intensive educational interventions during initial months, followed by extended follow-up periods, resulting in overall durations ranging from 6 months to 13 months [9,19]. One study [7] had an annual follow-up duration of 3 years. Numerous articles did not specify session durations, though available reports indicated sessions typically lasted between 30 minutes and 2 hours.

Selected studies employing control groups utilized diverse analytic approaches to identify differences in clinical parameters. Eight studies [8,11–13,15,18,19,23] compared HbA1c levels between intervention and control groups. Six studies [9,10,14, 16,17,22] assessed HbA1c changes within each group before and after the intervention, while the remaining studies without a control group compared outcomes pre-intervention and post-intervention. Nine studies [8,10,12–16,18,22] demonstrated significant reductions in HbA1c levels following patient education, all of which primarily employed direct, individual delivery methods. Some studies incorporated supplementary communication methods, such as telephone calls [13], messaging groups [8], and telepharmacy [16]. Educational sessions typically occurred 2 times to 6 times weekly, lasting between 30 minutes and 60 minutes; however, session lengths were frequently not reported explicitly. Pharmacists or clinical pharmacists were the primary educators in most studies, with only 1 study [12] explicitly involving a multidisciplinary team that included pharmacists. Most educational programs spanned approximately 6 months, consistent with established educational practices. Certain interventions tailored educational content specifically to individual patient needs [10,12,13,15], while others integrated widely recognized social work practices [8].

DISCUSSION

The present study demonstrates that providing education is a fundamental component of effective patient care, facilitating the achievement of desired therapeutic outcomes. T2DM is recognized as a metabolic disorder that may lead to various complications. Consequently, it is common to encounter T2DM patients with multiple comorbidities, particularly cardiovascular-related conditions [3]. Given the chronic nature of T2DM, evaluations of treatment efficacy should encompass clinical, humanistic, and economic outcomes [25]. Notably, almost all diabetes research includes multiple parameters of therapeutic effectiveness.

Most of the reviewed articles employed face-to-face instruction as the primary method of delivering education, with 1-study utilizing an electronic application. This preference for face-to-face teaching may reflect its advantages in enhancing patient engagement in treatment programs, allowing detailed explanations, improving patient adherence, and strengthening patient confidence [26–28]. The single study implementing an electronic application [21] also maintained direct interaction between pharmacists and respondents through face-to-face or virtual meetings during the intervention. According to existing research [28], despite easier access to electronic information, patients often still require face-to-face education to ensure accuracy of understanding. Since patients possess diverse characteristics and preferences, relying solely on online dissemination of information is imprudent [29]. Previous studies [30,31] suggest direct patient education can improve clinical outcomes. Interventions utilizing electronic devices effectively assist patients through reminders for step attainment targets, dietary records, and medication schedules; however, personalized education, patient data analysis, and tailored feedback remain essential for optimal diabetes self-management. Individualized education should be conducted directly by appropriate healthcare professionals rather than exclusively through automated systems or applications [32,33]. Several studies found that direct communication with healthcare providers enhanced outcomes and patient engagement [34,35].

The duration of educational interventions in this review ranged from 3 months to 3 years. Most studies reporting significant HbA1c improvements incorporated educational programs lasting around 6 months. In self-management education programs, the intervention duration significantly impacts efficacy. Extended educational interventions are necessary for achieving clinically meaningful HbA1c improvements. Prior studies indicated improved HbA1c outcomes following longer intervention durations, with variable intervention frequencies at different intervals [36,37]. Consistent with this assertion, the DESMOND program demonstrated no HbA1c improvement after a single 6-hour educational session [38]. However, 1 study implementing an educational program lasting only 3 months reported significant clinical improvements. This program was initiated during patient hospitalization and continued post-discharge. Educational sessions involved direct teaching methods, readily accessible patient platforms, and ongoing support throughout the intervention period. Utilizing multiple educational approaches is recommended to enhance intervention efficacy [39].

Intervention frequency in the reviewed studies ranged from 2 sessions to 16 sessions, with some studies allowing flexible frequency adjustments according to patient needs [8,21,23]. The frequency of interventions associated with improved clinical outcomes varied considerably. Studies reporting significant HbA1c improvements generally conducted between 3 educational sessions and 6 educational sessions. Previous research [36] indicates that decreasing intervention frequency after 2 years may lead to more stable achievement of therapeutic targets. Many studies did not specify session durations explicitly, though effective session durations typically ranged from 30 minutes to 60 minutes. Session length should be adjusted according to patient needs, with several studies suggesting shorter session durations as more effective for sustaining therapeutic target achievements [38,40–42].

Pharmacists served as educational providers, either individually or as part of multidisciplinary teams, frequently overseeing therapy monitoring and evaluation within their pharmaceutical responsibilities. Achieving clinical outcomes was not strictly dependent on the type of educational provider. While some studies demonstrated successful therapeutic outcomes with pharmacists as educators, others reported no significant improvement when pharmacists acted as sole educators [9,11, 17]. Likewise, studies involving multidisciplinary healthcare teams reported enhanced clinical outcomes [12]. Consequently, the current analysis cannot conclusively state that variations among educational providers influence clinical outcomes. Nonetheless, pharmacist involvement—whether individually or within a multidisciplinary team—appears essential for achieving desired clinical outcomes.

The educational content of each reviewed study is summarized in Table 3 [7–23]. Educational materials are more effective when initiated by investigating patients’ specific problems, emphasizing patient needs, minimizing disinterest in irrelevant topics, and reducing unnecessary time expenditure. This aligns with previous studies suggesting that identifying patient-specific needs before educational interventions enhances the effectiveness of diabetes education programs [43,44]. Educational providers should establish clear criteria for addressing patient challenges and create educational guidelines to standardize responses to drug-related issues, ensuring consistency among educators. Structured education within clinical practice benefits both patients and the healthcare system, according to prior research [45]. Providing personalized feedback on patient-specific issues is critical for achieving desired therapeutic outcomes, given that each patient faces unique challenges [33].

This systematic review highlights that educational programs for patients with diabetes mellitus require specific strategies and patterns to enhance glycemic outcomes (Tables 2 and 3) [7–23]. The findings may aid stakeholders in designing suitable educational program structures to assist T2DM patients in achieving desired clinical outcomes. Nevertheless, this systematic review has several limitations. Relevant studies might have been overlooked due to the restriction of our search to only 3 databases. Additionally, because we did not perform a quantitative analysis, we were unable to determine the magnitude or strength of the association between educational delivery methods and HbA1c outcomes. Most reviewed trials were conducted over a duration of 6 months or less, whereas T2DM management typically requires prolonged care. Therefore, conclusions regarding the long-term sustainability and efficacy of educational programs remain uncertain. Future reviews should consider assessing the sustainability of educational programs and incorporating clinical outcomes as metrics for evaluating educational performance.

CONCLUSION

Our findings indicate that direct face-to-face delivery methods are generally preferred for educational programs targeting patients with T2DM, occasionally supplemented by additional media to enhance teaching efficacy. Six-month educational programs were most common and frequently demonstrated clinical outcome improvements. Educational session frequency varied considerably; among programs demonstrating clinical outcome improvements, there was no consistent frequency pattern. Although most studies did not explicitly specify session duration, typical session lengths ranged from 30 minutes to 60 minutes. Pharmacist-led educational interventions—whether conducted individually or within multidisciplinary teams—can significantly enhance therapeutic outcomes in T2DM patients. Educational content should be tailored to individual patient needs, yet clear guidelines are necessary to standardize the core information that educators provide.

Notes

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

This work was supported by the Indonesian Education Scholarship (BPI) (No. 202209090846), and the Center for Higher Education Funding and Assessment Ministry of Higher Education, Science, and Technology of Republic Indonesia (Pusat Pelayanan Pembiayaan dan Asesmen Pendidikan Tinggi), and Indonesia Endowment Fund for Education (LPDP) through its financial support for education and research dissertations.

Acknowledgements

We would like to acknowledge the Indonesian Education Scholarship (BPI), Center for Higher Education Funding and Assessment Ministry of Higher Education, Science, and Technology of Republic Indonesia (Pusat Pelayanan Pembiayaan dan Asesmen Pendidikan Tinggi), and Indonesian Endowment Funds for Education (LPDP).

Author Contributions

Conceptualization: Mustikaningtias I, Yasin NM, Widayanti AW, Samodro P. Data curation: Mustikaningtias I, Yasin NM, Widayanti AW, Samodro P. Funding acquisition: Mustikaningtias I. Methodology: Mustikaningtias I, Yasin NM, Widayanti AW, Samodro P. Writing – original draft: Mustikaningtias I, Yasin NM, Widayanti AW, Samodro P. Writing – review & editing: Mustikaningtias I, Yasin NM, Widayanti AW, Samodro P.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram exhibiting article selection and exclusion. HbA1c, hemoglobin A1c. Source from Page MJ, et al. BMJ 2021;372:n71 [24].

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