Characteristics and perceptions of barriers to diabetes education of healthcare professionals in Thailand
Background
Diabetes education is integral to successful diabetes management. However, data about characteristics and barriers of diabetes education in clinical practice in Thailand is limited.

Aim
To describe characteristics of diabetes education and identify perceptions of barriers to diabetes education among administrators, doctors and other healthcare professionals working as diabetes educators (DEs) in Thailand.

Method
A survey was conducted in 613 hospitals (508 public and 105 private hospitals) across Thailand from December 2016 to March 2017. A self-completion questionnaire was sent to administrators, diabetes clinic doctors, and health professionals working as a DE to collect data about the workload, characteristics of diabetes education from DEs and perceived barriers to diabetes education from 3 groups of respondents.

Results
The overall response rate was 54.8% (58.3% public and 38% private hospitals). The response rate of administrators, doctors and DEs was 48.3%, 49.9% and 65.7%, respectively. The median (IQR) number of DEs per hospital surveyed was 4 (2,6). The median (IQR) number of patients per educator per week  was higher in public hospitals than private hospitals (70 [30,150] vs. 20 [10,30]).The health professionals working as a DE were outpatient nurses (84.1%), nutritionists (59.8%), pharmacists (53.6%), doctors (44.7%), inpatient nurses (34.2%), physical therapists (18.4%), health educators (15.1%), Thai traditional medicine staffs (7.7%) and dentists (3.2%). DEs self-reported the percentage+SD of patients receiving diabetes education in <30, 31-60, 61-120, 121-500 and >500 beds hospitals were 70±23, 73±21, 62±26, 63±26 and 46±27, respectively. Characteristics of diabetes education in public and private hospitals are presented in table 1. Self-reported factors perceived as barriers to diabetes education by respondents in public hospitals are shown in table 2.



Table 1. Characteristics of diabetic education programs in public and private hospitals 
	                                                                             Public hospitals	Private hospitals
Criteria to provide diabetes education, n (%)                     		
     Patients with newly diagnosed diabetes             	332 (93.5)	34 (70.8)
     Patients with uncontrolled diabetes                    	310 (87.3)	23 (47.9)
           Definition of uncontrolled diabetes 
                Fasting plasma glucose (mg/dL)                 183 (180,200)    150 (128,180)
                HbA1c (%)	                                                           8 (7,8)               7 (7,8)

     Patients with diabetes complication                    	225 (63.4)	21 (43.8)
Method of diabetes education, n (%)                                  		
     Individual education                                               	339 (95.5)	37 (77.1)
     Group education                                                     	282 (79.4)	14 (29.2)
Duration of education session, median (IQR), min per session		
     Individual education                                               	15(10,30)	30(12.5,30)
     Group education                                                     	30(20,30)	30(25,60)
Evaluation of diabetes education, n (%)                               		
     Successful 	                                                                   89(25.6)	16 (34)
     Uncertain outcome 	                                              141 (39.7)	16 (33.3)
     Non-evaluation                                                              	89 (25.1)	16 (33.3)


Table 2. Perceptions of barriers to diabetes education among different groups of respondents in public hospitals

          
	Administrators
(n=264)	Doctors
(n=269)	DEs
(n=355)
Non-compliance with recommended changes of unhealthy behavior	217 (82.2)	220 (81.8)	299 (84.2)
Lack of time for diabetes education by DEs due to other duties  	205 (77.7)	186 (69.1)	303 (85.4)*†  
Lack of interest in diabetes education from patients 	195 (73.9)	207 (77)	275 (77.5)
Lack of skill in DEs in assisting patients with behavioral change 	151 (57.2)	108 (40.1)	219 (61.7)†
Inadequate numbers  of DEs	115 (43.6)	118 (43.9)	203 (57.2)*†
Lack of suitable place to provide diabetes education	90 (34.1)	71 (26.4)	184 (51.8)*†
Lack of budget to support effective diabetes education	64 (24.2)	61 (22.7)	106 (29.9)†
Lack of suitable educational material	53 (20.1)	42 (15.2)	147 (41.4)*†

Data are presented as n (%).     *p<0.05 comparing between administrators and DEs,  † p<0.05 comparing between doctors and DEs

Discussion
The majority of the hospitals reported >60% of patients received diabetes education. Nevertheless, only 30% of DEs believed their diabetes education was successful while 60% of DEs were uncertain about their educational outcomes. Lack of evaluation after education was a diabetes education weakness in Thailand. Interestingly, all groups of respondents thought non-compliance with recommended changes of unhealthy behavior was a significant barrier to diabetes education. Nevertheless, every health professional knows that behavior change is difficult and requires motivation, planning and support. However, our DEs perceived time limitation due to other duties and a lack of skill to change unhealthy behaviors as barriers.  Furthermore, we observed that administrators and doctors tended to report a lower percentage of barriers than DEs. This difference in perception might be another obstacle to diabetes education in Thailand. Therefore, improvements in human resource, educational approach and clear educational role definitions for DEs are needed.