Sugumar V, Zhu Y, Doshi T, Wadhwani A, Akanbi E, Yusuf Ibrahim A, Joy T, Clemens KK. Specialist-led interventions to support equity-deserving populations with diabetes: A scoping review of the literature. World J Diabetes 2026; 17(8): 120392 [DOI: 10.4239/wjd.120392]
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Kristin K Clemens, Department of Medicine, Division of Endocrinology and Metabolism and Department of Epidemiology and Biostatistics, Western University, 268 Grosvenor Street PO BOX 5777, STN B, London N6A 4V2, Ontario, Canada. kristin.clemens@sjhc.london.on.ca
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Sugumar V, Zhu Y, Doshi T, Wadhwani A, Akanbi E, Yusuf Ibrahim A, Joy T, Clemens KK. Specialist-led interventions to support equity-deserving populations with diabetes: A scoping review of the literature. World J Diabetes 2026; 17(8): 120392 [DOI: 10.4239/wjd.120392]
Vithuyan Sugumar, Tanya Doshi, Arpana Wadhwani, Schulich School of Medicine and Dentistry, Western University, London N6A 4V2, Ontario, Canada
Yunxu Zhu, Kristin K Clemens, Lawson Research Institute, London N6A 4V2, Ontario, Canada
Emmanuel Akanbi, Department of Epidemiology and Biostatistics, Western University, London N6A 4V2, Ontario, Canada
Aisha Yusuf Ibrahim, Tisha Joy, Department of Medicine, Division of Endocrinology and Metabolism, Western University, London N6A 4V2, Ontario, Canada
Kristin K Clemens, Department of Medicine, Division of Endocrinology and Metabolism and Department of Epidemiology and Biostatistics, Western University, London N6A 4V2, Ontario, Canada
Author contributions: Sugumar V contributed to the study concept, identified studies, interpreted data and drafted the manuscript; Zhu Y contributed to the concept, identified studies, interpreted data and drafted the manuscript; Doshi T contributed to the concept, identified studies, interpreted data and drafted the manuscript; Wadhwani A, Yusuf Ibrahim A and Joy T interpreted the results and reviewed the manuscript; Clemens KK contributed to the concept, design, identification of studies, result interpretation and she edited the manuscript.
Conflict-of-interest statement: There are no conflicts of interest to disclose.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Corresponding author: Kristin K Clemens, Department of Medicine, Division of Endocrinology and Metabolism and Department of Epidemiology and Biostatistics, Western University, 268 Grosvenor Street PO BOX 5777, STN B, London N6A 4V2, Ontario, Canada. kristin.clemens@sjhc.london.on.ca
Received: February 26, 2026 Revised: March 30, 2026 Accepted: July 9, 2026 Published online: August 15, 2026 Processing time: 161 Days and 1.6 Hours
Abstract
BACKGROUND
Diabetes mellitus (DM) has a disproportionate impact on populations who also face barriers to specialist diabetes care (e.g., racialized people, those of lower socioeconomic status).
AIM
To identify specialist-led interventions to support the care of equity-deserving populations with DM.
METHODS
Using the Joanna Briggs Institute framework, we conducted a scoping review of the medical and grey literature to the spring of 2024. Equity deserving communities of interest included those of low socioeconomic status, people living in rural regions, sex and gender minorities, racialized people, people with disability, migrants, individuals experiencing homelessness, and Indigenous peoples. We aimed to understand the impact of specialist-led interventions on DM-related screening [e.g., glycated hemoglobin (HbA1c)] and outcomes (e.g., hospitalizations for DM complications).
RESULTS
Our broad search identified 1963 citations: 178 underwent full-text screening, and 28 papers met inclusion. Five major types of interventions were identified: (1) Provider education programs; (2) Patient education programs; (3) Community supports; (4) Multidisciplinary clinics; and (5) Telehealth. The impact of interventions on HbA1c was most often studied, followed by the adoption of lifestyle changes and use of cardiovascular- and kidney-protective medications. Patient and provider “empowerment”, the inclusion of multiple health disciplines, attention to the social determinants, and use of virtual tools appeared to be key components of program success. Stakeholder “buy-in” and devoted resourcing were also important.
CONCLUSION
Specialist DM care can be re-designed to support equity-deserving patients. Future studies could investigate the practicality, feasibility, sustainability, and economic impact of new care models across different healthcare settings and contexts.
Core Tip: Diabetes disproportionately affects equity-deserving populations, yet access to specialist care remains limited. This scoping review synthesizes evidence on specialist-led and specialist-supported diabetes interventions in high-income countries, identifying five effective care models: Provider education, patient education, community supports, multidisciplinary clinics, and telehealth. Patient and provider empowerment, interdisciplinary collaboration, attention to social determinants of health, and flexible delivery appear important to program success. Models that extend specialist expertise into primary care and community settings may overcome structural barriers to access. Our findings can inform equitable, scalable diabetes care design and future implementation-focused research.
Citation: Sugumar V, Zhu Y, Doshi T, Wadhwani A, Akanbi E, Yusuf Ibrahim A, Joy T, Clemens KK. Specialist-led interventions to support equity-deserving populations with diabetes: A scoping review of the literature. World J Diabetes 2026; 17(8): 120392
Diabetes mellitus (DM) is one of the most prevalent chronic diseases in the world. As of 2024, 589 million adults aged 20-79 years had DM, and worldwide, over 1 trillion USD was spent on diabetes[1].
DM disproportionately affects certain populations. Compared with White populations, the prevalence of DM is 2.3 times higher is South-East Asians, 1.9 times higher among Black, and 1.8 times higher among Arab and West Asian populations[2-4]. In Canada, Indigenous people have the highest prevalence of DM[5,6]. DM is also more common among those of lower income[7].
People disproportionately impacted by DM also face major barriers to health care[8]. They may lack the health literacy to monitor blood glucose and manage medications[9,10]. New migrants can experience communication challenges with health care providers, leading to anxiety, difficulty retaining information, and potential misunderstandings[11,12]. These barriers can compromise trust and result in delayed treatment and follow-up[11]. Among low-income patients with chronic conditions, medication non-adherence is a risk, and transportation challenges can make attending appointments difficult[13,14].
There have been efforts to develop DM care programs for underserved groups within the community. For example, the Sandy Lake and Diabetes Project in Canada, implemented community-wide interventions for type 2 diabetes mellitus (DM2), including establishing partnerships with Northern Store programs, setting up the infrastructure for home visits, and providing educational outreach[15]. In South-East Asians, DM programs have been offered in fitness facilities, religious institutions and community centres[16]. Access to specialty DM care, however, remains difficult. Diabetology services are traditionally hospital-based, requiring patients to travel to a single site to see one physician. Appointments are often time-limited and fragmented[17].
An essential first step to improving specialist DM care is to learn about previously successful strategies and interventions. In this scoping review, we aimed to identify specialist-led DM interventions for underserved populations, summarize their successful components, and highlight facilitators and barriers to their implementation in routine care.
MATERIALS AND METHODS
Study design
Our scoping review was guided by the Joanna Briggs Institute and the PRISMA-ScR frameworks[18,19]. We chose a scoping review rather than a systematic review style, because we were uncertain about the depth and breadth of research in this area. We expected to summarize a range of interventions, including their unique outcomes, benefits and limitations.
Research questions
What interventions have been developed to improve specialist-led DM/pre-DM care? What DM outcomes were focused upon? What were some of the features that contributed to the success of interventions? What were identified barriers?
Inclusion and exclusion criteria
We included studies of specialist-led interventions for equity-deserving groups. Specialist-led interventions were defined as those delivered either at specialist centres or overseen by a specialist in community settings such as primary care. Eligible studies included: Adults aged 18 years or older with DM or pre-DM who were of lower socioeconomic status, living in rural regions, sex and gender minorities, those who were racialized, had disabilities, were migrants, were experiencing homelessness, or who were Indigenous. We limited to studies conducted in high-income countries, as defined by the World Bank, to ensure relevance to our Canadian health care context[20]. Study designs included randomized controlled trials (RCT), cohort studies, qualitative studies, and quality improvement (QI) initiatives. We excluded: (1) Case series, chart reviews, letters, editorials, protocols and book chapters; (2) Articles not published in English; (3) Studies where full text articles were not available; and (4) Studies focused solely on drugs or technologies.
Search strategy
The search strategy was developed based upon our research questions and our inclusion and exclusion criteria. We did this in consultation with an experienced health sciences librarian. A combination of key words and Medical Subject Heading (MeSH) terms were used. Databases included EMBASE, MEDLINE, PsycINFO, Cochrane Library, PubMed and CINAHL Plus. A grey literature search was also conducted using terms such as diabetes and equity-deserving populations. We did this using Google Scholar, HealthData.org, CADTH, AHRQ, OAIster, the Sigma Repository, ClinicalTrials.gov and the World Health Organization. The first 20 citations from each source engine were reviewed and handled similarly to papers found in academic databases. Searches were conducted through April 2024.
Screening and extraction
Two authors (Zhu Y and Doshi T) independently screened titles and abstracts against inclusion and exclusion criteria. Citations were categorized as include, exclude, or uncertain. Full-text articles were screened by an additional author (Sugumar V). The first 10% of articles were reviewed as a calibration exercise to ensure a high level of agreement (90%). Following this, two authors independently assessed study eligibility. If both authors agreed on inclusion or exclusion of a citation, the decision regarding that citation was finalized. In the event of disagreement between authors, the senior author (Clemens KK) provided a resolution. Data extraction was performed in duplicate using a standardized abstraction form. The form was piloted on the first 10 studies and refined as necessary before extraction of the remaining articles.
RESULTS
Our search yielded 2140 citations, with 1963 citations remaining once duplicates were removed. A flow diagram of inclusion and exclusion criteria is provided in Figure 1.
Figure 1
PRISMA flow diagram of inclusions and exclusions.
Twenty-eight articles met inclusion criteria. The characteristics of included articles are provided in Table 1. Most studies were conducted in the United States, with one study each conducted in Korea, the United Kingdom, Australia, Canada, and Finland. Most studies were designed as QI or cohort studies and included participants with DM2 from Black and Hispanic communities in the United States. No eligible studies specifically evaluated specialist-led interventions for Indigenous peoples, sex and gender minorities, those with disabilities, migrants or people experiencing homelessness.
HbA1c decreased from 8.0% to 7.5% vs 8% to 7.8% in control. Total cholesteral decreased from 5.0 mmol/L to 4.8 mmol/L vs 5.0 mmol/L to 5.1 mmol/L in control
The most frequently assessed outcome was glycemic control via glycated hemoglobin (HbA1c), followed by adherence to self-management recommendations and medications. Other outcomes included weight loss, blood pressure, cholesterol levels, quality of life, and health care utilization, including emergency department visits and hospital admissions. Provider-level outcomes were assessed following the implementation of interventions in a few studies and included physician knowledge gained and confidence in DM management.
Interventions
Five types of DM interventions were identified: (1) Provider education programs; (2) Patient education programs; (3) Community supports; (4) Multidisciplinary clinics; and (5) Telehealth programs.
Provider education
The most frequently studied education program was Extension for Community Healthcare Outcomes (ECHO). ECHO uses a tele-education and knowledge-sharing approach to improve chronic disease management[21]. Expert multidisciplinary teams (hubs) are linked with primary care providers (spokes) through regular virtual educational sessions. Sessions begin with a didactic presentation delivered by an expert within the hub. Patient cases are then discussed to promote mentoring, peer-to-peer learning, and open dialogue. ECHO can be particularly helpful in under-resourced and medically underserved areas, where access to specialist services is limited[21].
In a large RCT of ECHO conducted in the United States, primary care clinics were randomized to ECHO Diabetes or usual care. Patients from clinics randomized to ECHO had improved glycemic control compared to usual care (the percent with an HbA1c > 9% decreased from 31.7% to 26.7%). They also had increased use of continuous glucose monitoring (CGM)[21]. In observational studies, ECHO helped improve provider knowledge and confidence managing DM[22]. In one study, 68.8% of clinician participants reported increased confidence in their ability to manage DM (48% felt confident at baseline)[23]. Patients whose providers participated in ECHO Diabetes were more likely to attend DM visits-72% visited their physician four or more times over the course of a year compared with 58% in usual care (P < 0.001)[24]. Other tele-mentoring programs have had a similar benefit on health care utilization[25].
Electronic consultations (E-consults) have also been studied as a means of education. E-consults promote asynchronous, provider-to-provider communication through a secure web-based platform. Primary care providers can obtain expert advice without requiring an in-person specialist visit[26]. In a QI study conducted in the United States, E-consults were found to be of particular benefit to women, Black, and uninsured patients. There was a decrease in HbA1c from 10.1% to 9.3% within six months of implementation[27].
Patient education
Patient education programs have focused on healthy eating, self-management strategies, and physical activity in underserved groups. In an RCT in the United States, centres were randomized to virtual vs face-to-face patient education sessions. Sessions were provided by a dietitian and nurse practitioner from a DM clinic. After 4 months, HbA1c decreased from 9.4% to 8.6% in the face-to-face group (P = 0.02) vs 9.6% to 9.3% in the virtual group (P = 0.19)[28]. Another RCT showed that in-person education programs improved nutritional knowledge (P = 0.02), and diet quality (P = 0.018), in Black populations[29]. After 18 months, there was a decrease in HbA1c levels by 0.58% vs 0.33% in the control group[29]. A QI initiative of technology-based patient education (e.g., continuous glucose monitoring) promoted uptake of treatment in minority populations. There was also a decrease in HbA1c levels by 0.98% after six months[30].
The impact of brief, text messaging has also been studied. Text messaging interventions provided tailored education, motivational messaging, and medication and blood glucose monitoring reminders[31,32]. In one RCT of Latino participants, those randomized to the intervention received three text messages per day to promote adherence to DM treatment. Over six months participants in the intervention arm had a significantly lower HbA1c than those receiving usual care (P = 0.03)[31]. In an RCT studying text messages alongside website-based educational resources vs. usual care, participants in the intervention arm had improved behaviours and greater confidence in their dietary habits[33].
Community outreach and support
Community supports are purposive, time-limited, and mobile activities designed to reach populations at health risk and increase their access to services[34]. Several studies examined the utility of delivering specialty DM care within primary care settings. In a QI study, there was a 356% increase in the number of patients with DM seen in the outreach clinic, compared with baseline[35].
The engagement of community health workers (CHW) in DM care has also showed benefit. A CHW is a frontline public health worker who brings health and social services to patients, through culturally appropriate outreach, education, support, and advocacy[36]. In an RCT of a CHW program in Latinos with DM2 in the United States, participants randomized to the intervention had HbA1c levels that were 0.51% lower than those receiving usual after 12 months[37]. Reducing financial barriers to attending DM appointments and helping patients access medications have also proven to improve clinic attendance and HbA1c[38,39].
Multidisciplinary care clinics
Traditional specialist care typically involves one-on-one visits with a DM provider in a hospital setting-this can contribute to siloed and fragmented care[17]. Multidisciplinary care clinics bring multiple clinicians together to see patients during a single appointment and may be particularly advantageous for equity-deserving populations[40,41]. In a QI study, endocrinologists, nurses, nurse practitioners, community workers, and pharmacists jointly cared for low-income patients from the United States. There was a reported decline in HbA1c by up to 4%, as well as improvements in low-density lipoprotein cholesterol (LDL-C)[42]. Similar benefits have been described with the inclusion of mental health workers onto the multidisciplinary team. Another study demonstrated the effectiveness of multidisciplinary care in rural communities, showing that compared with usual care, multidisciplinary care helped to improve blood pressure, cholesterol and HbA1c[40]. Medical, nursing, and pharmacy trainees can also play a meaningful role in DM care. In an observational cohort study of a shared student-led clinic offering free medical appointments to individuals with DM2 in the United States, there was a decrease in HbA1c from 9.7% to 9.2%, as well as improved clinic efficiency observed at 12 months[41].
Telehealth
Telehealth programs use electronic information and telecommunication technologies to support long-distance clinical health care[43]. Telehealth may be particularly effective for patients living in rural areas or regions without access to tertiary or specialized DM care. In an RCT from South Korea, a central DM specialist connected virtually with patients on a weekly basis. There was a significant decrease in HbA1c from 8.0% to 7.5% (P = 0.01), and a reduction in cholesterol levels (P = 0.043)[44]. An RCT evaluating a comprehensive telehealth intervention led by nurses demonstrated improvement in self-management and mental health in uncontrolled DM2. Over 12 months, HbA1c decreased by 10.2% to 8.6% vs 10.2% to 9.2% in the control group[45]. In an observational study from Finland, the provision of a teleconsultation service for individuals with DM living in remote communities was associated with an HbA1c decrease from 8.0% to 7.6% (P = 0.007), an LDL-C decrease from 3.3 mmol/L to 2.7 mmol/L (P = 0.001), and a reduction in systolic blood pressure of 6 mmHg (P = 0.004)[46]. Similar telehealth models in the United States have demonstrated benefits in rural and underserved populations. In one observational study, HbA1c levels decreased from 9.6% to 8.5%[47].
Determinants of successful programs
Promotion of empowerment: Empowering patients and health care providers appears to be a key determinant of successful interventions. Individuals living with chronic disease may feel that their health is beyond their control[48]. DM self-management and education can promote patient empowerment, improve medication adherence, and encourage lifestyle changes[30,49-51]. Motivational messaging may foster a better sense of control over chronic disease and can be tailored to participant demographics and needs[31,32]. Patient empowerment can be promoted through advocates such as family members, or patient navigators. Their inclusion in DM care can help reduce sociocultural barriers and improve engagement with DM services[37].
Ensuring that primary care providers are empowered to support patients with DM also appears beneficial. The ECHO model promotes provider knowledge and confidence in the delivery of high-quality DM care[22]. When providers are more knowledgeable in the conditions they treat, patients may feel more comfortable returning to their clinician for ongoing care[24,52].
Attention to social determinants: Equity-deserving populations are disproportionately affected by food insecurity, housing instability, poverty and social isolation-factors that can hinder their ability to prioritize health[8,53]. Attention to these determinants is essential to the success of care programs. For example, while education focused on dietary management of DM may be beneficial to some, there are patients unable to afford DM-friendly foods. Similarly, although virtual tools may improve access to DM care, the “digital divide” persists. In the United States, 20% do not have an internet subscription[50]. Poor internet connectivity was in fact, reported as a challenge in several of the interventions included in this review[28,33,47]. Even when technology is available, some patients lacked the training or experience necessary to access virtual platforms and meaningfully engage with online resources[50].
Transportation also poses a barrier to full participation in DM care[37,48]. The barrier can persist even in the context of telehealth, as patients must still travel to laboratories to obtain bloodwork required for DM monitoring.
For patients who do not speak the primary language of the country in which they live, health literacy challenges and difficulty engaging with practitioners may further limit the effectiveness of DM programs. Interpretation services may help mitigate these barriers and improve patient participation.
Interdisciplinary care: Given that physicians alone may not possess all the skills required to optimally manage DM, engaging multidisciplinary professionals is essential. Across the studies included in this review, a diverse team contributed to DM care.
Stakeholder “buy-in”: Stakeholder engagement is critical to successful implementation of new DM interventions[54,55]. Gunasekaran et al[35] highlighted the importance of clinician buy-in during the development of new models of care. In their study, DM services were expanded to include a telehealth and a satellite DM clinic. Engaged and motivated staff were essential to managing the additional responsibilities associated with new programming. Hassaballa et al[52], also emphasized the importance of community buy- in. In their study, clinicians collaborated with community members to develop DM workshops, arrange home visits, set up support groups, and develop healthy eating programs for minority populations. Engaging with community partners can ensure that new interventions are culturally sensitive and appropriate.
Appropriate resourcing: New interventions require upfront investment, both financial and personnel-related.
Several studies reported that virtual interventions were actually more costly and resource-intensive than traditional models of care[28,45,49] (Table 1). Online programs and services must be developed and maintained, and staff are required to manage, support, and troubleshoot systems.
Similarly, establishing multidisciplinary clinics requires resourcing. Sufficient staff need to be recruited and adequate physical space needs to be secured. Investment and careful pre-planning are essential[23,43,48,49].
DISCUSSION
Diabetes specialty services can be restructured to better support equity-deserving populations. Provider and patient-level education, multidisciplinary clinics, community outreach, and telehealth supports might improve DM-related screening and outcomes.
It appeared that multidisciplinary clinics and telehealth had the most quantitative benefit on HbA1c when studied in observational and QI studies. It is important to emphasize that studies included small cohorts of patients and should be interpreted with caution as they are subject to bias and confounding. Importantly, there were only a few RCTs included and none of them compared different types of interventions directly. In the RCTs included, interventions appeared to have a small to medium benefit on study outcomes compared with usual care.
When applying results to clinical practice, it is important to understand local context. For example, telehealth interventions may best support patients from rural areas as they often live far from specialty care. For groups with low access to technology, the ECHO DM program might be helpful. This program leverages technology to educate providers without putting responsibility on the patient. If patients don’t have Internet, one could consider motivational text messaging as this doesn’t require an Internet connection. This type of electronic communication can also be easily adapted into different languages.
For lower income groups, education programs could be augmented with financial or food support. Enrolment in the New York State Health Homes program, a program that assists Medicaid-insured patients with management of their chronic conditions through comprehensive medical care and social services, was found to increase outpatient follow-up visits[38]. Patients offered prescription medications for their DM without requiring a copayment had a better HbA1c and adherence[39]. CHW can also assist with system navigation in DM[37]. This could also be helpful for immigrants or newcomers who may not speak the predominant language in that country.
From the included literature, it was clear that the development of new interventions requires a positive, change-focused organizational culture, collaboration across stakeholders, and adequate resourcing. This might require substantial effort in strained health care systems. Thoughtful planning and sustained investment may nevertheless yield long-term benefits for both patients and providers.
This scoping review included 28 studies conducted across multiple countries. Despite a broad search strategy, most focused upon DM interventions for Black and Hispanic populations, individuals from a lower socioeconomic background, and patients in the United States. We did not identify published studies examining specialist DM support for Indigenous people, sex and gender minorities, individuals with disabilities, newcomers, or people experiencing homelessness. This is an important limitation of the current evidence base and restricts the generalizability of our findings. The absence of studies involving these groups suggests research and QI needs. As noted, most studies were observational and so their effects may be over-stated.
Next steps
Future research could study how to launch these care programs in routine care. Using implementation science frameworks would be beneficial. In RE-AIM the following domains are considered: Reach (engagement of target population), effectiveness (achievement of primary outcome or clinical impact), adoption (uptake by providers and organizations), implementation (feasibility of intervention) and maintenance (long-term sustainability of the intervention)[56]. The Consolidated Framework for Implementation Research (CFIR) may also be a helpful tool. The framework draws attention to the need to understand contextual barriers and facilitators to program development. These include factors like program complexity, organization, leadership, and resource constraints[57]. CFIR promotes consideration of organizational readiness and structure. This might assist with understanding the efficacy and adoption of multidisciplinary clinics for DM care, and how structural limitations such as workface, and digital heterogeneity might affect the feasibility of telehealth.
CONCLUSION
As patients with DM become increasingly complex and diverse, the provision of culturally relevant and tailored specialist DM care is essential. By mapping the landscape of potentially effective care models, this review helps set the stage for future care, research and QI.
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