NURSING

Aims: The prevalence of diabetes mellitus remains high worldwide and has long-term health implications and impacts on the quality of life of those affected. As a catastrophic disease, diabetes mellitus has the potential to burden national healthcare financing, including in Indonesia. Improving standardized diabetes mellitus services, starting from primary healthcare facilities, is a critical effort that is hoped to address this potential burden. The aim of this study is to synthesize and obtain information on the challenges of implementing minimum standards for diabetes mellitus services in Indonesia. Method: This study is a narrative literature review using the PRISMA framework. In this review, inclusion and exclusion criteria to gather articles from Pubmed, ScienceDirect, Google Scholar, ProQuest, and Emerald. The MMAT instrument was used to select eligible articles in study. Results: Our findings indicate that 19 eligible journal articles related to the challenges of implementing minimum standards for diabetes mellitus services in Indonesia. The synthesis results showed that there are challenges in implementing minimum standards for diabetes mellitus services in Indonesia, particularly in the internal and external aspects of patients, primary healthcare facilities, and the government. Conclusions: The challenges of implementing minimum standards for diabetes mellitus services in Indonesia need to be addressed through enhancing the interpersonal and practical skills of healthcare providers, strengthening the role of primary healthcare facilities and the government, ensuring adequate funding support, and establishing appropriate indicators that reflect the field's conditions as a reference for achieving the implementation of minimum standards for diabetes mellitus services in Indonesia.


INTRODUCTION
Diabetes Mellitus (DM) is a major noncommunicable disease (NCD) that is widely prevalent worldwide.Global data from 2017 showed that diabetes is responsible for 1.4 million deaths worldwide, or 2.5% of all fatalities (1).In Indonesia, the prevalence of diabetes mellitus has increased by 0.5% compared to previous years, reaching 2% (2).A chronic metabolic condition called diabetes mellitus is characterized by a rise in the level of blood sugar along with a fall in insulin secretion and/or insulin resistance in the body.This disease is chronic and cumulative, and therefore often occurs in older age.Diabetes is also a catastrophic disease that can cause complications in the heart, kidneys, and reduce the quality of life of patients (1).
According to data from the Social Security Administering Body for Health (BPJS Kesehatan), catastrophic illness accounted for 25 to 31 percent of the total cost of health insurance in 2020.BPJS Kesehatan spent IDR 20 trillion in 2020 to cover catastrophic disease treatments and medications, including Diabetes Mellitus (3).The escalating burden of catastrophic disease expenses on national health insurance poses a threat to the national healthcare system.Due to the potential for complications, this disease also presents a number of challenges, from prevention and primary care to referral and rehabilitative care (4)(5)(6).
The government seeks to improve the quality of diabetes mellitus care by instituting minimum service standards through Minister of Health Regulation No. 43 of 2016.Comprehensive application of standardized diabetes mellitus care from primary care to advanced care.Improving primary care is one of the pillars of efforts for avoiding maintaining diabetes mellitus in order to prevent additional increases.This standardized service aims to improve the expected outcomes of diabetes mellitus care, prevent complications and mortality, and enhance diabetes mellitus patients' quality of life (7).
In the minimal service standard for diabetes mellitus at primary care facilities (Puskesmas), there are four main pillars, namely education, physical activity, nutritional therapy, and pharmacological therapy (7).In practice, standardized diabetes mellitus care still encounters obstacles; therefore, it is necessary to identify the obstacles that must be overcome in order to implement the minimal service standards for diabetes mellitus.However, due to Indonesia's immense geographical factors, the evaluation of diabetes mellitus treatment barriers is fragmented in certain areas and does not completely describe the efforts of diabetes mellitus care that refer to the four pillars of minimal service standards.Consequently, examining previous studies is an effective and efficient method for identifying obstacles to standardizing diabetes care in Indonesian primary health care facilities.

Design
This study was a narrative literature review that aimed to synthesize information from previous research articles.Secondary data in the form of research articles published in journal databases were selected and examined carefully using specific methods and tools to produce high-quality results.In the process of selecting journal articles, we referred to the PRISMA framework (8), which has been commonly used in various literature review studies.The obtained articles were then analyzed and categorized according to the purpose of the research, which was to identify challenges in implementing standardized care for diabetes mellitus in Indonesia.

Inclusion and Exclusion Criteria
We also used several criteria restrictions to increase the accuracy of the selected articles, which were journal articles published from 2019 to 2023, with the research conducted in healthcare facilities in Indonesia, focusing on primary healthcare facilities, using English or Indonesian language, and only focusing on adult diabetes mellitus patients.We excluded articles that did not meet the exclusion criteria, which received an MMAT score of <80 and all literature review studies.

Data Extraction
In this study, the researchers conducted a search for health journal articles related to standardized care or treatment of diabetes mellitus in journal databases such as Pubmed, ScienceDirect, Google Scholar, ProQuest, and Emerald.We used the SPIDER method to formulate research questions and identify keywords that we used to search for articles in journal databases.The keyword sequence used was as follows:

Instrument
To ensure the quality of the selected articles, the researchers used the mixed method appraisal tool (MMAT), which can be used for a wide range of studies, including quantitative, qualitative, and mixed-method research.MMAT uses a threshold value of 80 to determine whether the selected articles are of high quality or not (9,10).In addition, this study also used software tools such as rayyan.ai to help sort the extracted data according to the research needs.

RESULTS AND DISCUSSIONS
The search for journals resulted in 2,762 articles.All of the results were then sorted and checked for eligibility to obtain the best articles to be synthesized.The following is the process of article selection based on the PRISMA framework: From the review results, it was found that the majority of articles were quantitative research (57.89%).Qualitative research accounted for 36.84% and the rest were mixed-method research (5.26%).There is a difference in the achievement of standardized minimum care between remote, border, and island areas (DTPK) and non-DPTK (0.000), as well as between eastern and western regions of Indonesia (0.0009).The achievement of standardized minimum care for DM is quite high, and there are differences between districts/cities, DTPK, and regions.There is also no correlation between physical and non-physical funds with standardized minimum care for DM.

Results
continues to increase every month in 2020, indicating an increasing achievement of DM SPM.The high achievement of DM in Bandung can be seen from two perspectives.Firstly, there is a possibility that the DM target population is small, and there are actually more DM patients than what has been targeted.Secondly, there is an indication that the recording and reporting of patients by name and address has not been implemented properly, thus there is a possibility of double registration.The obstacles that arise are related to facilities and infrastructure, such as the absence of PTM Kit Posbindu due to limited budget, and not all UPT Puskesmas have trained personnel to provide services.Rachmawati et al.
2019 Quantitative 100 The majority of patients were women (67.9%).There was a significant relationship between diabetes literacy and self-care of diabetes (p=0.011) with an odds ratio of 0.43.Age was also found to have an impact on the diabetes literacy ability of patients (median 64 years).The provision of healthcare services for patients with comorbid hypertension and diabetes mellitus includes health promotion, disease prevention, diagnosis, and treatment.However, the long-term care for these patients is still low.Our analysis indicates that there are several challenges in providing quality and standardized care for patients with diabetes mellitus in primary healthcare facilities.The following are the results of the article synthesis in this study: The internal aspects of patients are related to their demographic characteristics, behavior, and health status.Several studies have shown that female respondents dominate the research population.The results of these studies indicate that women have better compliance rates than male diabetes mellitus patients (11)(12)(13)(14).In a study conducted to identify the health behaviors of diabetes mellitus patients, it was found that the majority of respondents were men.Some factors contributed to the less adaptive health behavior towards diabetes treatment provided by healthcare workers at Puskesmas, such as appropriate diet choices, daily routines, physical activity, mental and social balance, and healthy lifestyle behavior (15,16).
One of the most commonly found health behaviors in reviews is the lack of selfmanagement of diabetes care planned by healthcare workers at Puskesmas and the low access to diabetes mellitus services provided by Puskesmas (17,18).On the other hand, although standard diabetes care has been provided, some diabetes mellitus patients also experience several other complications due to diabetes (>50%), resulting in various access to healthcare services provided by Puskesmas.The more complex the patient's condition, the more likely they are to choose to access healthcare services at higher-level healthcare facilities (12,13,19).

External Aspects of Patients
The cultural environment of diabetes mellitus patients' residence also poses a challenge that healthcare workers must face in providing diabetes mellitus services to patients.Due to Indonesia's cultural diversity, several areas, particularly in rural areas, still believe in supernatural healing processes for a disease.For example, in Bali society, people's trust in traditional healers' treatment is also applied to diabetes mellitus patients' self-care.This belief sometimes causes diabetes mellitus patients' access to the care provided by Puskesmas to be low or the care that has referred to the 4 minimal diabetes mellitus service pillars to be disrupted due to interactions with traditional herbs (15).
In other communities, such as communal cultures for traditional events, diabetes mellitus patients forget to take their prescribed medication.Therefore, diabetes mellitus patients' compliance decreases and is not in line with the treatment plan (20).
Educating and empowering the patient's family as medication supervisors is essential to support the achievement of the 4 minimal diabetes mellitus service pillars, including education, physical activity, good nutrition, and regular pharmacological therapy (15).

Primary Healthcare Facility Aspects
In many studies, adequate support for infrastructure and competent human resources is essential to achieving quality and standard diabetes mellitus services.Sufficiency of healthcare workers in standard diabetes mellitus care is essential.Not only is it sufficient, but healthcare workers who provide health services must also have the necessary skills.In a study conducted by Kurniawati, Suryawati, and Arso, not all healthcare workers providing minimal diabetes mellitus services have received training.Skills in providing education, screening, referrals, treatment, monitoring, and evaluation are necessary in minimal diabetes mellitus service activities.The still low ability of healthcare workers to provide standard diabetes mellitus care due to lack of training risks making the achievement of SPM (minimum health service standards) not optimal (21-23).
The integration of various multidisciplinary approaches in providing standardized diabetes services is the core of healthcare service in the dimension of healthcare professionals (11,16,24,25).The burden of diabetes services is not only on doctors but also requires support from nurses in promoting and preventing activities in POSBINDU (Pos Pembinaan Terpadu), nutrition experts in providing education about the necessary nutrition for patients, and pharmacists related to providing appropriate information about diabetes medication consumption given to patients (23,26).Support from facilities and infrastructure for education, screening, nutrition therapy, and pharmacology for diabetes patients is also important.In screening diabetes cases, a lack of blood glucose detection equipment will cause low screening coverage.Adequate educational materials are also needed for diabetes patients.For example, in a study by Puri et al., patients felt that education would be more effective if provided in the form of a booklet (11,25).Education for diabetes patients has a significant impact as it will improve knowledge, attitudes, behaviors, and selfawareness towards the disease and treatment regimen (12).
Puskesmas as a provider of promotive and preventive services is the appropriate system for building closer relationships with patients to improve their understanding and ability to manage diabetes care that has been given.

Government Aspects
Government support as policymakers is the key to the success of minimal diabetes service standards in Indonesia.Clear regulations governing minimum service standards will serve as a guide for primary health facilities in providing standardized diabetes services.However, there are still obstacles in its implementation, such as funding schemes that are not appropriate, unstructured organization, and data collection as indicators of achieving minimum service standards in Puskesmas that are not appropriate (4).
Healthcare financing for patients is covered by BPJS Kesehatan (27), but in practice, standardized diabetes services require more funding support.In one study, it was mentioned that funding for diabetes screening is still insufficient, so assistance from village funds is needed.However, the use of village funds for the purchase of blood glucose sticks is considered inappropriate.Other challenges that arise are related to inadequate facilities and infrastructure, such as in POSBINDU for non-communicable diseases services due to limited funds.The need for standard operational procedures that are in line with Government guidelines is needed by healthcare workers and primary health facilities in the implementation of minimum service standards for diabetes care (21).
The uneven distribution of financing for diabetes services is also evident in the allocation of funds by the government.For example, primary health facilities in rural areas and in the Eastern part of Indonesia receive lower diabetes service funds than primary health facilities in urban areas and the Western part of Indonesia.These macro challenges need to be addressed by the government so that the achievement of minimum diabetes service standards can be improved even in the areas that really need it (28).
The achievement of minimum service standard indicators for diabetes care in one study shows an uneven distribution between one Puskesmas working area and another.
Although the cumulative achievement of minimum diabetes service standards showed results above the target, this may mean miscalculations between target population data and the population data served (23,28).In one study, the target population for achieving minimum diabetes service standards refers to data from the Central Statistics Agency (BPS), but the data obtained by health workers at Puskesmas are the results of the PIS-PK survey they conducted in the field.Thus, sometimes the number obtained has a difference (22,29).

CONCLUSION
According to the findings of this study, there are still obstacles in achieving the minimal service standards for diabetes mellitus care.Four aspects were identified as the main challenges: patient internal factors, patient external factors, primary healthcare facility factors, and government factors.To achieve the maximum implementation of diabetes mellitus minimum service standards, healthcare workers need to understand the appropriate approach to providing care to patients, taking into account patient characteristics and cultural background.In delivering standardized healthcare services based on the four pillars of diabetes mellitus minimum service standards, healthcare workers also need to have proficient practical and interpersonal skills.The primary healthcare facilities and government have a responsibility to provide funding and capacity-building training programs for healthcare workers in providing diabetes mellitus minimum service standards.The role of the government is crucial in ensuring the implementation of the minimum service standards by providing guidance, improving control, monitoring, and evaluation of the implementation and funding of the program.The accuracy between the survey data and achievement indicators must be ensured by the government to avoid miscalculation.

Figure 1 .
Figure 1.PRISMA framework for Literature Screening DM patients were women (n=426).Some DM patients experienced complications (such as retinopathy 31.7%,nerve problems 20.2%, etc.).Both men and women experienced high levels of distress (>72%) and low physical activity levels (>58%).The challenges faced by the elderly health program (Prolanis) were difficulty in reaching and maintaining patients.Budiastutik et al. 2023 Quantitative 80 The majority of patients in the study were women (80.5%) and over 40 90.7%), with low participation in diabetes prevention education (61.0%).The prevalence of prediabetes cases was high (76.4%).The ownership of BPJS Kesehatan had an OR of 5.95, a history of hypertension had an OR of 3.25, and hypertension had an OR of 2.14 for the incidence of further DM.Wahidin et al. 2023 Quantitative 80

Figure 2 .
Figure 2. Illustration of the Challenges of Standardized Minimum Care Implementation for Diabetes Mellitus Patients in Indonesia

Authors Year of Published Study Design MMAT Score
Puri et al. 2022 Quantitative 80 The majority of the DM patients in the study were women (76.5%).Most patients received DM nutrition education for less than 30 minutes (60.3%), every 1-2 months (59.8%), and from a doctor (57.5%).Patients expressed satisfaction with the nutrition education service (73.2%) and indicated a need for nutrition education (88%), but required a booklet (20.4%).The perceived benefits included an increase in knowledge (51.9%), improvement in quality of life (27.9%),reduction in blood glucose levels (10.0%), and reduction in body weight (1.1%).2022 Quantitative 100 The majority of DM patients were women (54%) and over 44 years of age (72%).Patients mostly require medication to control their blood patients: 1) Lack of knowledge and skills in screening peripheral neuropathy by healthcare providers, lack of tools and facilities at health centers for neuropathy screening, high workload of health centers, lack of human resources, and difficulty in reaching patient understanding.2) These factors lead to lost followup of patients and an increased incidence of peripheral neuropathy in DM patients.Widayanti et al., 2021 Qualitative 80 There are several variables that affect the ability of patients with DM to have good and healthy eating habits: 1) Changing meal schedules.2) Medication characteristics, access to health centers (difficult to reach health centers due to busy schedules or distance from residence), experience of side effects, and social burden (cultural activities: traditional events).Puri et al. 2021 Quantitative 100 The majority of the respondents were women (95.8%).The frequency of receiving nutrition education at the primary health care center was only once a month (41.7%), and less than 10 patients (68.7%).Nutrition education for patients with diabetes mellitus has been shown to improve knowledge, attitude, behavior, and patient outcomes.The achievement of DM SPM in Bandung city is 115.35%, but its distribution is still uneven among each region.The DM service SPM