[Perspective of patients on type-2 diabetes and their relationship with primary care health professionals: a qualitative study]

Understanding the impact of endometriosis on women's life: an integrative review of systematic reviews

BACKGROUND

Endometriosis is a challenging chronic condition with a significant impact on women's well-being. This systematic review of systematic reviews aims to assess the evidence investigating the intricate interplay between endometriosis and quality of life (QoL).

METHODS

A systematic review was performed for English-language studies up to January 2022 to identify systematic reviews with and without meta-analysis analyzing quantitative or qualitative data The following databases were searched: Scopus, PubMed, Embase, Web of Science and Cochrane Central Register of Controlled Trials. Participants/population were women with endometriosis, and the outcomes included were all reported outcomes evaluating the impact of endometriosis on women's QoL (PROSPERO 2021 CRD42021289347).

RESULTS

15 systematic reviews were identified. 8 included meta-analysis: 4 explored the prevalence of mental health problems, and 1 analyzed, respectively, the overall impact of endometriosis, headache migraine, and sexual function. 7 articles reported on the mental consequences, and three sexual functioning. One was a qualitative review. The impact of the relationships with the healthcare system was analyzed in 3 reviews. Pain is a hallmark of endometriosis. Infertility and sexual problems are also frequent. Depression, anxiety, and stress represent significant contributors to lessening women's QoL. Women have frustrating relationships with the healthcare system: the complex and long diagnostic process, lack of treatment effectiveness, and persistence of symptoms contribute to emotional challenges. Negative cognitive patterns developed by women with emotional distress, such as catastrophizing and fear-avoidance behaviors, amplify the experience of pain.

CONCLUSION

The limitations of this review are the high degree of heterogeneity of papers that include many factors, including comorbidities, and use of medical care that may impact QoL, and that most of them were cross-sectional. Endometriosis is a chronic disease that significantly impacts all domains of women's lifes. Pain, infertility, and stress linked with depression, and anxiety significantly influence QoL. Women are dissatisfied with the care they receive.

What and how do different stakeholders contribute to intervention development? A mixed methods study

Background: UK Medical Research Council guidelines recommend end-user involvement in intervention development. There is limited evidence on the contributions of different end-users to this process. The aim of this Study Within A Trial (SWAT) was to identify and compare contributions from two groups of end-users - people with diabetes' (PWD) and healthcare professionals' (HCPs), during consensus meetings to inform an intervention to improve retinopathy screening uptake. Methods: A mixed method, explanatory sequential design comprising a survey and three semi-structured consensus meetings was used. PWD were randomly assigned to a PWD only or combined meeting. HCPs attended a HCP only or combined meeting, based on availability. In the survey, participants rated intervention proposals on acceptability and feasibility. Survey results informed the meeting topic guide. Transcripts were analysed deductively to compare feedback on intervention proposals, suggestions for new content, and contributions to the final intervention. Results: Overall, 13 PWD and 17 HCPs completed the survey, and 16 PWD and 15 HCPs attended meetings. For 31 of the 39 intervention proposals in the survey, there were differences (≥10%) between the proportion of HCPs and PWD who rated proposals as acceptable and/or feasible. End-user groups shared and unique concerns about proposals; both were concerned about informing but not scaring people when communicating risk, while concerns about resources were mostly unique to HCPs and concerns about privacy were mostly unique to PWD.  Fewer suggestions for new intervention content from the combined meeting were integrated into the final intervention as they were not feasible for implementation in general practice. Participants contributed four new behaviour change techniques not present in the original proposals: goal setting (outcome), restructuring the physical environment, material incentive (behaviour) and punishment. Conclusions: Preferences for intervention content may differ across end-user groups, with feedback varying depending on whether end-users are involved simultaneously or separately.

Women's Health and Gynecology: Old Challenges and New Insights

The complexity of women's health goes far beyond medical and surgical knowledge and the achievements of the clinical specialty of Obstetrics and Gynecology, spanning not just the research dimensions of molecular biology, genetics, epidemiology, or health services but also being influenced by gender, social, and psychological relevant factors [...].

What and how do different stakeholders contribute to intervention development? A mixed methods study

Background: UK Medical Research Council guidelines recommend end-user involvement in intervention development. There is limited evidence on the contributions of different end-users to this process. The aim of this Study Within A Trial (SWAT) was to identify and compare contributions from two groups of end-users - people with diabetes' (PWD) and healthcare professionals' (HCPs), during consensus meetings to inform an intervention to improve retinopathy screening uptake. Methods: A mixed method, explanatory sequential design comprising a survey and three semi-structured consensus meetings was used. PWD were randomly assigned to a diabetes only or combined meeting. HCPs attended a HCP only or combined meeting, based on availability. In the survey, participants rated intervention proposals on acceptability and feasibility. Survey results informed the meeting topic guide. Transcripts were analysed deductively to compare feedback on intervention proposals, suggestions for new content, and contributions to the final intervention. Results: Overall, 13 PWD and 17 HCPs completed the survey, and 16 PWD and 15 HCPs attended meetings. For 31 of the 39 intervention proposals in the survey, there were differences (≥10%) between the proportion of HCPs and PWD who rated proposals as acceptable and/or feasible. End-user groups shared and unique concerns about proposals; both were concerned about informing but not scaring people when communicating risk, while concerns about resources were mostly unique to HCPs and concerns about privacy were mostly unique to PWD.  Fewer suggestions for new intervention content from the combined meeting were integrated into the final intervention as they were not feasible for implementation in general practice. Participants contributed four new behaviour change techniques not present in the original proposals: goal setting (outcome), restructuring the physical environment, material incentive (behaviour) and punishment. Conclusions: Preferences for intervention content may differ across end-user groups, with feedback varying depending on whether end-users are involved simultaneously or separately.

Direct and Indirect Costs Related to Physical Activity Levels in Patients with Diabetes Mellitus in Spain: A Cross-Sectional Study

Diabetes mellitus (DM) is a global public health concern. DM is importantly linked to the modern lifestyle. Lifestyle-based interventions currently represent a critical preventive and therapeutic approach for patients with DM. Increasing physical activity has proven multiple benefits to prevent this condition; however, there is still room for further progress in this field, especially in terms of the effect of exercise in patients with already established DM. This study intends to examine the economic relationship between physical activity and direct/indirect costs in patients with DM. We analyze a national representative sample (n = 1496) of the general population of Spain, using available data from the National Health Survey of 2017 (NHS 2017). Our results show that 63.7% of the sample engaged in some degree of physical activity, being more frequent in men (67.5%), younger individuals (80.0%), and those with higher educational levels (69.7%). Conversely, lower levels of physical activity were associated with female sex, older subjects, and various comorbidities. Our study estimates that 2151 € per (51% in direct costs) patient may be saved if a minimum level of physical activity is implemented, primarily, due to a decrease in indirect costs (absenteeism and presenteeism). This study shows that physical activity will bring notable savings in terms of direct and indirect costs in patients with DM, particularly in some vulnerable groups.

Type 1 Diabetes Patient Experiences Before and After Transfer from a Paediatric to an Adult Hospital

INTRODUCTION

The management of type 1 diabetes (T1D) is especially complex during adolescence when youths are transferred to adult care centres. The objectives of this qualitative study were to: a) determine the expectations of young T1D patients prior to transfer, b) evaluate the transfer process between the 2 centres, and c) evaluate the therapeutic education and care programme (TECP) in the adult centre from their point of view.

MATERIAL AND METHODS

Opinion sampling of adolescents from 2018-2019 was performed: Phase 1: adolescents with T1D prior to transfer to the adult hospital; Phase 2: adolescents with T1D one or two years after transfer and having undergone TECP. A focus group (1.5h) and semi-structured interviews (45 min) were performed and taped, transcribed, and sent to the participants for confirmation. Date analysis was performed of the transcriptions of the focus group and interviews. Fragments were selected and meta-categories created.

RESULTS

Eleven youths accepted to participate: 7 in Phase 1, 4 repeated in Phase 2 and 4 more transferred 2 years previously were added. The meta-categories obtained were: 1) perception of the quality of care and therapeutic education in the paediatric hospital. 2) transfer to the adult hospital. 3) experience of the youths 1-2 years after transfer and having undergone TECP. The data are presented in narrative form and are supported with text fragments of the participants' discussions.

DISCUSSION AND CONCLUSIONS

Analysis of patients' experience complemented by clinical-educational evaluation of TECP provides understanding of the perspectives of youths on the complexity of living with a chronic disease since childhood. It also provides information regarding the factors favouring quality care and therapeutic education, the complexity of transfer from paediatric to adult care, determination of the strong and weak points and the establishment of strategies to improve the programme.

'It just wasn't going to be heard': A mixed methods study to compare different ways of involving people with diabetes and health-care professionals in health intervention research

Background

Guidelines recommend involving intervention users in the intervention development process. However, there is limited guidance on how to involve users in a meaningful and effective way.

Objective

The aim of this Study within a trial was to compare participants’ experiences of taking part in one of three types of consensus meetings—people with diabetes‐only, combined people with diabetes and health‐care professionals (HCPs) or HCP‐only meeting.

Design

The study used a mixed methods convergent design. Quantitative (questionnaire) and qualitative (observation notes and semi‐structured telephone interviews) data were collected to explore participants’ experiences. A triangulation protocol was used to compare quantitative and qualitative findings.

Participants

People with diabetes (recruited via multiple strategies) were randomly assigned to attend the people with diabetes or combined meeting. HCPs (recruited through professional networks) attended the HCP or combined meeting based on their availability.

Results

Sixteen people with diabetes and 15 HCPs attended meetings, of whom 18 participated in a telephone interview. Participants’ questionnaire responses suggested similar positive experiences across the three meetings. Observation and semi‐structured interviews highlighted differences experienced by participants in the combined meeting relating to: perceived lack of common ground; feeling empowered versus undervalued; needing to feel safe and going off task to fill the void.

Conclusions

The qualitative theme ‘needing to feel safe’ may explain the dissonance (disagreement) between quantitative and qualitative data. In this study, involving patients and HCPs simultaneously in a consensus process was not found to be as suitable as involving each stakeholder group separately.

Side effects and practices to improve management of type 2 diabetes mellitus from the viewpoint of patient experience and health care management. A narrative review

INTRODUCTION

There is an alarming increase in the number of patients with type 2 diabetes mellitus. This increase is causing personal, family, social, economic, and political problems. The aim of this article is to review the side effects of treatments, the complications suffered by patients, and the practices to improve management of this disease from the viewpoint of the experience of patients and health care management.

MATERIAL AND METHODS

A narrative review was conducted of studies on type 2 diabetes mellitus published in English and Spanish indexed in PubMed, Science Direct, Cinahl, MedLine, Psychology and Behavioral Sciences Collection, and Google academic. A total of 1,118 articles were found, 42 of which referred to the objectives of the review and met the inclusion criteria.

RESULTS

The side effects and complications experienced by patients and their perception that they do not receive adequate information, together with poor satisfaction, lead to non-adherence to treatment, which impairs patient health and increases health care costs. The proposals in the reviewed studies guide the actions to improve treatment adherence and, thus, quality of life of patients, to decrease side effects and mortality and, therefore, the costs associated to type 2 diabetes mellitus through: 1) quick and easy access to medical care, 2) quality health education, and 3) participation of patients in the decisions about their treatment and in self-management of their disease to make minimum changes in their lifestyles.

Patient-reported outcomes in type 2 diabetes mellitus: patients' and primary care physicians' perspectives in the Spanish health care system

OBJECTIVE

Understanding patients' and physicians' perceptions of type 2 diabetes mellitus (T2DM) management and treatment has important implications for diabetes care, allowing the identification of clinical practice issues that could be improved, leading to patients' better understanding of the illness and, consequently, healthier self-management behaviors. The objective of this study was to identify differences between physicians' and T2DM patients' perceptions related to health status, patient-reported outcomes assessments, and T2DM management and treatment, in routine clinical practice in Spain.

METHODS

This was an observational, cross-sectional study including 1,012 T2DM patients and 974 physicians from 47 and 52 Spanish provinces, respectively. An electronic structured self-administered questionnaire containing 17 questions was designed aiming to address both physicians' and patient's perceptions on overall T2DM health status and patient-reported outcomes.

RESULTS

T2DM patients perceived a worse health status (40% reported having a "good" and 38% a "neither good nor bad" health status) compared with physicians' perceptions (77% thought patients had a "good" health status). Most patients answered being "satisfied" or "neither satisfied nor unsatisfied" with the given information, while physicians considered that patients were "satisfied" or "very satisfied" with the information for self-monitoring blood glucose and treatment administration. Fifty-seven percent of patients reported that medical recommendations were "important", while 58% of physicians considered it as "very important". Fifty-three percent of patients perceived that their current T2DM treatment suited their preferences "quite a lot", and this was lower than the proportion of physicians (69%) that believed this for their patients. Additionally, a lower percentage of patients (53%) than physicians (79%) believed that their treatment improved their health-related quality of life "quite a lot". All differences between patients and physicians were statistically significant (P<0.001).

CONCLUSION

Patients and physicians demonstrate different views concerning all questions related to T2DM health status and diabetes management and treatment (information, recommendations, satisfaction, and preferences).

[Patient and health professional perceptions on the quality of care provided to diabetic patients]

OBJECTIVE

To describe the knowledge and perceptions of patients and health professionals on the factors that influence the quality and continuity of care of diabetic patients provided in Primary Care.

MATERIAL AND METHODS

A qualitative study using a phenomenological perspective.

PARTICIPANTS

Medical and nursing professionals working in Primary Care Centres in the city of Zaragoza, and patients with diabetes mellitus attended in the same centres. Two group (focus group) and 6 individual interviews were carried out in February and March 2010. A predetermined script, with the variables to explore, was used.

RESULTS

The patients and health professionals interviewed identified problems in assuming diabetes as a chronic disease. Among the factors related to success in changing habits and lifestyles, were gender (women showed greater difficulties to change), type of job and work situation. Health professionals identified the availability of guidelines and protocols, and personal motivation as factors that work in favour; and lack of time and current information systems as factors that hamper the provision of good quality care. There were discrepancies among health professionals as regards the role played by patient groups and associations.

CONCLUSIONS

It is important to take into account the factors that make changes in habits and lifestyles difficult, such as gender and the employment situation, when designing actions aimed at modifying risk factors in diabetic patients.

Living with diabetes: quality of care and quality of life

BACKGROUND

The aim of this research was to characterize the experience of living with diabetes mellitus (DM) and identify patients' opinions of the quality of care received and the results of interventions.

METHODS

A descriptive, exploratory evaluation study using qualitative methodology was performed. Participants consisted of 40 adult patients diagnosed with DM and followed up in a public hospital in Barcelona, Spain. A semistructured interview and a focus group were used and a thematic content analysis was performed.

RESULTS

Patients described DM as a disease that is difficult to control and that provokes lifestyle changes requiring effort and sacrifice. Insulin treatment increased the perception of disease severity. The most frequent and dreaded complication was hypoglycemia. The main problems perceived by patients affecting the quality of care were related to a disease-centered medical approach, lack of information, limited participation in decision-making, and the administrative and bureaucratic problems of the health care system.

CONCLUSION

The bureaucratic circuits of the health care system impair patients' quality of life and perceived quality of care. Health professionals should foster patient participation in decision-making. However, this requires not only training and appropriate attitudes, but also adequate staffing and materials.

Using qualitative methods to inform the trade-off between content validity and consistency in utility assessment: the example of type 2 diabetes and Alzheimer's disease

BACKGROUND

Key stakeholders regard generic utility instruments as suitable tools to inform health technology assessment decision-making regarding allocation of resources across competing interventions. These instruments require a 'descriptor', a 'valuation' and a 'perspective' of the economic evaluation. There are various approaches that can be taken for each of these, offering a potential lack of consistency between instruments (a basic requirement for comparisons across diseases). The 'reference method' has been proposed as a way to address the limitations of the Quality-Adjusted Life Year (QALY). However, the degree to which generic measures can assess patients' specific experiences with their disease would remain unresolved. This has been neglected in the discussions on methods development and its impact on the QALY values obtained and resulting cost per QALY estimate underestimated. This study explored the content of utility instruments relevant to type 2 diabetes and Alzheimer's disease (AD) as examples, and the role of qualitative research in informing the trade-off between content coverage and consistency.

METHOD

A literature review was performed to identify qualitative and quantitative studies regarding patients' experiences with type 2 diabetes or AD, and associated treatments. Conceptual models for each indication were developed. Generic- and disease-specific instruments were mapped to the conceptual models.

RESULTS

Findings showed that published descriptions of relevant concepts important to patients with type 2 diabetes or AD are available for consideration in deciding on the most comprehensive approach to utility assessment. While the 15-dimensional health related quality of life measure (15D) seemed the most comprehensive measure for both diseases, the Health Utilities Index 3 (HUI 3) seemed to have the least coverage for type 2 diabetes and the EuroQol-5 Dimensions (EQ-5D) for AD. Furthermore, some of the utility instruments contained items that could not be mapped onto either of the proposed conceptual models.

CONCLUSIONS

Content of the utility measure has a significant impact on the treatment effects that can be observed. This varies from one disease to the next and as such contributes to lack of consistency in observable utility effects and incremental utility scores. This observation appears to have been omitted from the method development considerations such as reference methods. As a result, we recommend that patients' perspectives obtained via qualitative methods are taken into consideration in the ongoing methods development in health state descriptions for generic utility instruments. Also, as a more immediate contribution to improving decision making, we propose that a content map of the chosen utility measure with patient-reported domains be provided as standard reporting in utility measurement in order to improve the transparency of the trade-offs in relation to patient relevance and consistency.

Expectations held by type 1 and 2 diabetes mellitus patients and their relatives: the importance of facilitating the health-care process

AIM

To understand the expectations held by type 1 and 2 diabetes mellitus (DM 1 & 2) patients and their relatives regarding the health-care provided to them.

DESIGN

qualitative. Focus groups.

SETTING AND PARTICIPANTS

Andalusia. A theoretical sample that includes the most characteristic profiles. Thirty-one subjects with DM. segmentation characteristics receiving health-care for DM in Primary or Specialized care, living in urban and rural areas, men and women, age, varying diagnosis times, DM course and consequences. Subjects were recruited by health-care professionals at reference care centres.

RESULTS

Patients expect their health-care professionals to be understanding, to treat them with kindness and respect, to have good communication skills, to provide information in a non-authoritarian manner while fully acknowledging patients' know-how. Regarding the health-care system, their expectations focus on the system's ability to respond when required to do so, through a relevant professional, along with readily available equipment for treatment. The expectations of people affected by DM1 focus on leading a normal life and not having their educational, labour, social and family opportunities limited by the disease. Expectations in people with DM2 tend towards avoiding what they know has happened to other patients.

CONCLUSIONS

'Facilitating', is a key word. Both the health-care system and its professionals must pay keener attention to the emotional aspects of the disease and its process, adopting a comprehensive approach to care. It is vital that health-care professionals take an active interest in the course of their patient's disease, promoting accessibility and an atmosphere of trust and flexibility.

[Problems and solutions in health care for chronic diseases. A qualitative study with patients and doctors]

BACKGROUND

Chronic diseases represent a challenge for health systems and the professionals most involved in chronic care. Despite biomedical advances, the results of care for chronic problems are not as good as they should be.

OBJECTIVE

To find out what doctors and patients think of care for some of the main chronic illnesses; to detect concrete areas of deficit and lack of satisfaction felt by both sides and possible lines of improvement; to raise mutual understanding between patients and doctors.

PARTICIPANTS

Forty-one patients with fibromyalgia or diabetes mellitus, carers for people with Alzheimer's and breast cancer patients. Forty-three family doctors involved in health care delivery to this kind of patient.

METHODS

Four discussion groups. Transcription and syntactical, semantic and pragmatic contents analysis, with both pre-established and emerging categories of consensus.

RESULTS

Patients thought, with different nuances as a function of the problem put forward, that questions of respectful, human and integrated care, clear and suitable information, and consistent follow-up were important and insufficiently covered by doctors and health services. Doctors thought that many of their efforts in caring for these patients were useless, and thought it important to reconsider their clinical responsibilities and the patient-doctor relationship. Doctors highlighted the limitations in the health care resources available for working with these patients.

CONCLUSIONS

To tackle prevalent chronic problems requires, in the view of doctors and patients, important modifications that are related mainly to the kind of relationship between the two, with new clinical responsibilities and certain organisational care delivery features.

[Can we improve management and control of chronic diseases?]

OBJECTIVE

To evaluate the effectiveness of interventions aimed at improving the quality and outcome of chronic disease management.

METHODS

Systematic review of the literature.

INCLUSION CRITERIA

Clinical trials in English and Spanish that assess the effectiveness of 1 or more strategies for improving quality and outcome in asthma, diabetes, hypertension, and congestive heart failure. Interventions were classified in line with a conceptual model in 6 categories: organizational changes, community participation, information systems, clinical practice design, decision-making support, and self-management. The outcomes considered were: health service utilization, chronic disease management, clinical outcomes, quality of life, satisfaction, and self-management indicators.

RESULTS

Thirty seven studies with 38 interventions were included. The most common interventions were those that investigated changes in health care design, followed by those analysing information systems and decision-making support. The most complex interventions, in terms of the overall number of strategies, including support for self-management, showed more likelihood of positive effects in clinical management and clinical outcomes. Few interventions achieved improvements in use of health care services, though patients perceived substantial improvements.

CONCLUSIONS

In order to improve quality and effectiveness of chronic disease management, it is necessary to take a systematic view including proactive health care systems and patients taking an active role in managing their disease. These programmes should combine, at the least, organizational strategies, design of clinical practice and patient self-management.

[Perceptions and expectations on primary health care: a new form of identifying improvements in the care system]

OBJECTIVE

To analyse the opinions of the users of primary care on the care that they receive and to identify the principal areas of satisfaction.

DESIGN

Qualitative study using discussion groups and open interviews during the period January-May 2003.

SETTING

Health areas of Valladolid, Spain.

PARTICIPANTS

The inclusion criteria were: to have attended a primary care clinic at sometime and to be between 35 and 80 years old. Recruitment was carried out through key informants, using the snowball technique.

METHOD

6 discussion groups and interviews with representatives of 3 nursing and 1 residents association were carried out. Structural sampling was carried out as regards the variables that influenced satisfaction. The conversations were recorded using tape recorders and literally transcribed on paper. The analysis of the texts was carried out by 2 investigators and concordance was sought between them.

RESULTS

The principal areas related to satisfaction were: the treatment received from the professionals, which is considered a fundamental part of care, combined with the technical quality, continuity of the care, the admission services, the bureaucratic procedures, the barriers for accessing specialised services, and waiting lists.

CONCLUSIONS

Personalized care, the time dedicated by the professional, the continuity of care, and waiting lists are the principal areas related to the perceived satisfaction of the patients. The possible responses to improve this situation are: the implementation of changes in the care management and organisation which would simplify the procedures, investment of resources (human and economic), changes in the model of the professional-patient relationship, and improvements in undergraduate and postgraduate training.