Quantifying and understanding the roles of diabetes educators in Malaysian primary health clinics: a mixed-methods study

Diabetes educators (DEs) play a critical role in supporting self-management and improving clinical outcomes among people with diabetes. However, their roles within primary healthcare settings in Malaysia remain underexplored, particularly with respect to time allocation for diabetes care and the challenges they face. A mixed-methods cross-sectional study was conducted in two phases from January 2022 until August 2023. Phase 1 involved a time‒motion study of 51 DEs across 43 public primary care clinics in Negeri Sembilan, which were observed over five working days to quantify the time spent across different activity domains. Phase 2 consisted of three in-depth interviews and five focus group discussions with 27 purposively sampled DEs. The quantitative data were analysed via descriptive statistics, whereas thematic analysis was applied to the qualitative transcripts. Five domains of DE activities were identified: diabetes care, non-diabetes care, administrative, supportive, and personal. DEs spent most of their time on diabetes care (63.3%), but two-thirds of this was indirect care, especially documentation. Non-diabetes responsibilities consumed approximately 26.5% of their time. The qualitative findings revealed three overarching themes influencing DE roles: organisational, patient-related, and personal factors. A central theme of resilience emerged, reflecting DEs’ coping strategies amid multiple roles demands, documentation burdens, and systemic constraints. This study provides new insights on how DEs allocate their time and challenges to Malaysia’s primary health clinics. Although they were able to dedicate substantial time to diabetes care, their effectiveness appeared to be hindered by administrative burden and role conflict. Targeted interventions are needed to streamline workflows, reduce documentation burdens by integrating information system, enhance leaders’ engagement in diabetes care, and clarify DE roles to strengthen diabetes care services in PHCs.