Health system challenges in organizing quality diabetes care for urban poor in South India

Assessing perceptions of nursing knowledge, attitudes, and practices in diabetes management within Chinese healthcare settings

Background

Effective management of diabetes mellitus (DM) involves comprehensive knowledge, attitudes, and practices (KAP) by nurses, which is essential for optimal patient care and aiding patients in their self-management of the condition.

Method

This survey evaluates nurses' self-assessed knowledge, attitudes, and practices (KAP) related to diabetes management, focusing on their perceptions of personnel expertise and care approaches. Using a stratified sampling method, the survey was disseminated across various online platforms from January 2023 to February 2024 within China, including WeChat and Sina Weibo. We employed binary logistic regression and Chi-square tests to explore the statistical correlates of KAP related to DM.

Results

A total of 4,011 nurses participated, revealing significant perceived knowledge deficiencies in specialized DM management areas, with only 34% (n = 1,360) proficient in current pharmacological treatments. Attitudinal assessments showed that 54% (n = 2,155) recognized the importance of cultural competence in dietary counseling. Practices were strong in routine glucose monitoring (96%, n = 3,851) but weaker in psychological support (68%, n = 2,736). Regression analysis indicated significant effects of experience on KAP, where nurses with 1-5 years of experience were more likely to show better knowledge (OR = 1.09; p = 0.08), and those with advanced degrees demonstrated higher competence (OR = 1.52; p = 0.028). Marital status influenced attitudes, with single nurses more likely to exhibit positive attitudes (OR = 0.49; p < 0.001), and work environment impacted knowledge, with hospital-based nurses more knowledgeable (OR = 1.15; p = 0.14). Additionally, gender differences emerged, with male nurses showing greater knowledge (OR = 1.65; p = 0.03) and better practices in diabetes care (OR = 1.47; p = 0.04).

Conclusion

The study underscores the critical need for targeted educational programs and policy interventions to enhance nursing competencies in DM management. While the study provides valuable insights into nurses' perceptions of their competencies, future research should incorporate objective knowledge assessments to ensure a comprehensive understanding of their actual capabilities. Interestingly, the data also suggests a substantial opportunity to leverage technology and inter-professional collaboration to further enhance DM management efficacy among nurses, fostering an integrated care approach.

Many hops, many stops: care-seeking "loops" for diabetes and hypertension in three urban informal settlements in the Mumbai Metropolitan Region

Background

The burden of Non-Communicable Diseases (NCDs) in urban informal settlements across Lower and Middle Income Countries is increasing. In recognition, there has been interest in fine-tuning policies on NCDs to meet the unique needs of people living in these settlements. To inform such policy efforts, we studied the care-seeking journeys of people living in urban informal settlements for two NCDs-diabetes and hypertension. The study was done in the Mumbai Metropolitan Region, India.

Methods

This qualitative study was based on interviews with patients having diabetes and hypertension, supplemented by interactions with the general community, private doctors, and public sector staff. We conducted a total of 47 interviews and 6 Focus Group Discussions. We synthesized data thematically and used the qualitative software NVivo Version 10.3 to aid the process. In this paper, we report on themes that we, as a team, interpreted as striking and policy-relevant features of peoples' journeys.

Results

People recounted having long and convoluted care-seeking journeys for the two NCDs we studied. There were several delays in diagnosis and treatment initiation. Most people's first point of contact for medical care were local physicians with a non-allopathic degree, who were not always able to diagnose the two NCDs. People reported seeking care from a multitude of healthcare providers (public and private), and repeatedly switched providers. Their stories often comprised multiple points of diagnosis, re-diagnosis, treatment initiation, and treatment adjustments. Advice from neighbors, friends, and family played an essential role in shaping the care-seeking process. Trade-offs between saving costs and obtaining relief from symptoms were made constantly.

Conclusion

Our paper attempts to bring the voices of people to the forefront of policies on NCDs. People's convoluted journeys with numerous switches between providers indicate the need for trusted "first-contact" points for NCD care. Integrating care across providers-public and private-in urban informal settlements-can go a long way in streamlining the NCD care-seeking process and making care more affordable for people. Educating the community on NCD prevention, screening, and treatment adherence; and establishing local support mechanisms (such as patient groups) may also help optimize people's care-seeking pathways.

The role of the private sector in noncommunicable disease prevention and management in low- and middle-income countries: a series of systematic reviews and thematic syntheses

PURPOSE

Conduct six systematic reviews investigating for-profit private sector roles in NCD prevention and management in low- and middle-income countries (LMICs) through our a priori framework's pillars.

METHODS

Six systematic reviews and thematic syntheses were performed between March-August 2021, Six databases, websites of relevant organizations, and references lists of included studies were comprehensively searched. Studies published in English from 2000 onwards involving the pillar of interest, for-profit private sector, NCD prevention/management, and LMIC context were included. Results were synthesized using an inductive thematic synthesis approach.

RESULTS

Ultimately, 25 articles were included in the PPP review, 33 in Governance and Policy, 22 in Healthcare Provision, 15 in Innovation, 14 in Knowledge Educator, and 42 in Investment and Finance. The following themes emerged: PPPs (coordination; financial resources; provision; health promotion; capacity building; innovation; policy); Governance/Policy (lobbying; industry perception; regulation); Healthcare Provision (diagnosis/treatment; infrastructure; availability/accessibility/affordability); Innovation (product innovation; process innovation; marketing innovation; research; innovation dissemination); Knowledge Educator (training; health promotion; industry framework/guideline formation); Investment and Finance (treatment cost; regulation; private insurance; subsidization; direct investment; collaborative financing; innovative financing; research).

CONCLUSION

These findings will be instrumental for LMICs considering private sector engagement. Potential conflicts of interest must be considered when implementing private sector involvement.

Scaling-up integrated type-2 diabetes and hypertension care in Cambodia: what are the barriers to health system performance?

Background

Non-communicable diseases (NCDs) such as type-2 diabetes (T2D) and hypertension (HTN) pose a massive burden on health systems, especially in low- and middle-income countries. In Cambodia, to tackle this issue, the government and partners have introduced several limited interventions to ensure service availability. However, scaling-up these health system interventions is needed to ensure universal supply and access to NCDs care for Cambodians. This study aims to explore the macro-level barriers of the health system that have impeded the scaling-up of integrated T2D and HTN care in Cambodia.

Methods

Using qualitative research design comprised an articulation between (i) semi-structured interviews (33 key informant interviews and 14 focus group discussions), (ii) a review of the National Strategic Plan and policy documents related to NCD/T2D/HTN care using qualitative document analysis, and (iii) direct field observation to gain an overview into health system factors. We used a health system dynamic framework to map macro-level barriers to the health system elements in thematic content analysis.

Results

Scaling-up the T2D and HTN care was impeded by the major macro-level barriers of the health system including weak leadership and governance, resource constraints (dominantly financial resources), and poor arrangement of the current health service delivery. These were the result of the complex interaction of the health system elements including the absence of a roadmap as a strategic plan for the NCD approach in health service delivery, limited government investment in NCDs, lack of collaboration between key actors, limited competency of healthcare workers due to insufficient training and lack of supporting resources, mis-match the demand and supply of medicine, and absence of local data to generate evidence-based for the decision-making.

Conclusion

The health system plays a vital role in responding to the disease burden through the implementation and scale-up of health system interventions. To respond to barriers across the entire health system and the inter-relatedness of each element, and to gear toward the outcome and goals of the health system for a (cost-)effective scale-up of integrated T2D and HTN care, key strategic priorities are: (1) Cultivating leadership and governance, (2) Revitalizing the health service delivery, (3) Addressing resource constraints, and (4) Renovating the social protection schemes.

Population Preferences for Primary Care Models for Hypertension in Karnataka, India

Importance

Hypertension contributes to more than 1.6 million deaths annually in India, with many individuals being unaware they have the condition or receiving inadequate treatment. Policy initiatives to strengthen disease detection and management through primary care services in India are not currently informed by population preferences.

Objective

To quantify population preferences for attributes of public primary care services for hypertension.

Design, Setting, and Participants

This cross-sectional study involved administration of a household survey to a population-based sample of adults with hypertension in the Bengaluru Nagara district (Bengaluru City; urban setting) and the Kolar district (rural setting) in the state of Karnataka, India, from June 22 to July 27, 2021. A discrete choice experiment was designed in which participants selected preferred primary care clinic attributes from hypothetical alternatives. Eligible participants were 30 years or older with a previous diagnosis of hypertension or with measured diastolic blood pressure of 90 mm Hg or higher or systolic blood pressure of 140 mm Hg or higher. A total of 1422 of 1927 individuals (73.8%) consented to receive initial screening, and 1150 (80.9%) were eligible for participation, with 1085 (94.3%) of those eligible completing the survey.

Main Outcomes and Measures

Relative preference for health care service attributes and preference class derived from respondents selecting a preferred clinic scenario from 8 sets of hypothetical comparisons based on wait time, staff courtesy, clinician type, carefulness of clinical assessment, and availability of free medication.

Results

Among 1085 adult respondents with hypertension, the mean (SD) age was 54.4 (11.2) years; 573 participants (52.8%) identified as female, and 918 (84.6%) had a previous diagnosis of hypertension. Overall preferences were for careful clinical assessment and consistent availability of free medication; 3 of 5 latent classes prioritized 1 or both of these attributes, accounting for 85.1% of all respondents. However, the largest class (52.4% of respondents) had weak preferences distributed across all attributes (largest relative utility for careful clinical assessment: β = 0.13; 95% CI, 0.06-0.20; 36.4% preference share). Two small classes had strong preferences; 1 class (5.4% of respondents) prioritized shorter wait time (85.1% preference share; utility, β = -3.04; 95% CI, -4.94 to -1.14); the posterior probability of membership in this class was higher among urban vs rural respondents (mean [SD], 0.09 [0.26] vs 0.02 [0.13]). The other class (9.5% of respondents) prioritized seeing a physician (the term doctor was used in the survey) rather than a nurse (66.2% preference share; utility, β = 4.01; 95% CI, 2.76-5.25); the posterior probability of membership in this class was greater among rural vs urban respondents (mean [SD], 0.17 [0.35] vs 0.02 [0.10]).

Conclusions and Relevance

In this study, stated population preferences suggested that consistent medication availability and quality of clinical assessment should be prioritized in primary care services in Karnataka, India. The heterogeneity observed in population preferences supports considering additional models of care, such as fast-track medication dispensing to reduce wait times in urban settings and physician-led services in rural areas.

Development process of a clinical guideline to manage type 2 diabetes in adults by Ayurvedic practitioners

Background

Type 2 diabetes mellitus (T2DM), a common chronic health condition, has major health and socioeconomic consequences. In the Indian subcontinent, it is a health condition for which individuals commonly consult Ayurvedic (traditional medical system) practitioners and use their medicines. However, to date, a good quality T2DM clinical guideline for Ayurvedic practitioners, grounded on the best available scientific evidence, is not available. Therefore, the study aimed to systematically develop a clinical guideline for Ayurvedic practitioners to manage T2DM in adults.

Methods

The development work was guided by the UK's National Institute for Health and Care Excellence (NICE) manual for developing guidelines, the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, and the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. First, a comprehensive systematic review was conducted which evaluated Ayurvedic medicines' effectiveness and safety in managing T2DM. In addition, the GRADE approach was used for assessing the certainty of the findings. Next, using the GRADE approach, the Evidence-to-Decision framework was developed, and we focused on glycemic control and adverse events. Subsequently, based on the Evidence-to-Decision framework, a Guideline Development Group of 17 international members made recommendations on Ayurvedic medicines' effectiveness and safety in T2DM. These recommendations formed the basis of the clinical guideline, and additional generic content and recommendations were adapted from the T2DM Clinical Knowledge Summaries of the Clarity Informatics (UK). The feedback given by the Guideline Development Group on the draft version was used to amend and finalize the clinical guideline.

Results

A clinical guideline for managing T2DM in adults by Ayurvedic practitioners was developed, which focuses on how practitioners can provide appropriate care, education, and support for people with T2DM (and their carers and family). The clinical guideline provides information on T2DM, such as its definition, risk factors, prevalence, prognosis, and complications; how it should be diagnosed and managed through lifestyle changes like diet and physical activity and Ayurvedic medicines; how the acute and chronic complications of T2DM should be detected and managed (including referral to specialists); and advice on topics like driving, work, and fasting including during religious/socio-cultural festivals.

Conclusion

We systematically developed a clinical guideline for Ayurvedic practitioners to manage T2DM in adults.

A clinical guideline-based management of type 2 diabetes by ayurvedic practitioners in Nepal: A feasibility cluster randomized controlled trial protocol

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a common chronic condition with significant health and socioeconomic consequences. In Nepal, T2DM is a common disease for which people consult ayurvedic (traditional medical system) practitioners and use ayurvedic medicines. Strong concerns remain about the suboptimal T2DM management of many patients by ayurvedic practitioners, and therefore, based on the best available scientific evidence, we have developed a clinical guideline for managing T2DM by ayurvedic practitioners. The research question to be addressed by a definitive cluster randomized controlled trial (RCT) is whether the introduction of a clinical guideline can improve the management of T2DM by ayurvedic practitioners in Nepal as compared to usual ayurvedic management (i.e., without any clinical guideline). In preparation for this future work, this current study aims to determine the feasibility of undertaking the definitive cluster RCT.

METHODS

This is a 2-arm, feasibility cluster RCT with a blinded outcome assessment and a qualitative evaluation. The study is conducted in 12 public and private ayurveda centers in and outside the Kathmandu Valley in Nepal (1:1 intervention:control). Eligible participants should be new T2DM adult patients (i.e., treatment naïve) - the glycated hemoglobin level should be 6.5% or above but less than 9%. At least 120 participants (60/group) will be recruited and followed up for 6 months. Important parameters, needed to design the definitive trial, will be estimated, such as the standard deviation of the outcome measure (i.e., glycated hemoglobin level at 6-month follow-up), intraclass correlation coefficient, cluster size, recruitment, the time needed to recruit participants, follow-up, and adherence to the recommended ayurvedic medicine. Semi-structured qualitative interviews will be conducted with around 20 to 30 participants and all the participating ayurvedic practitioners to explore their experiences and perspectives of taking part in the study and of the intervention and a sample of eligible people declining to participate in the study to explore the reasons behind nonparticipation.

DISCUSSION

We are now conducting a feasibility cluster RCT in Nepal to determine the feasibility of undertaking the definitive cluster trial. The first participant was recruited on 17 July 2022. If the feasibility is promising (such as recruitment, follow-up, and adherence to the recommended ayurvedic medicine), then the parameters estimated will be used to design the definitive cluster trial. Decisions over whether to modify the protocol will mainly be informed by the qualitative data.

Socio-demographic, behavioural and clinical factors influencing control of diabetes and hypertension in urban Mysore, South India: a mixed-method study conducted in 2018

BACKGROUND

Inadequate control of diabetes and hypertension is a major concern in India because of rising mortality and morbidity. Few studies in India have explored factors that influence control of diabetes and hypertension. The current study aimed to improve the understanding of multifactorial influence on the control of diabetes and hypertension among patients in Primary Health Care Settings(PHC) of urban Karnataka.

METHODS

We used a mixed-method study design, within a project aiming to improve non-communicable disease (NCD) continuum of care across PHC in Mysore city, India, conducted in 2018. The quantitative study was conducted among 399 patients with diabetes and/or hypertension and a logistic regression model was used to assess the factors responsible for biological control levels of diabetes and hypertension measured through Glycated Haemoglobin(HbA1c) and blood pressure. Further, in-depth interviews(IDI) were conducted among these patients and the counsellors at PHCs to understand the barriers and enablers for better control.

RESULT

The quantitative assessment found odds of poor control amongst diabetics' increased with older age, longer duration of disease, additional chronic conditions, and tobacco consumption. For hypertensives, odds of poor control increased with higher body mass index(BMI), alcohol consumption, and belongingness to lower social groups. These findings were elaborated through qualitative assessment which found that the control status was affected by stress as a result of family or financial worries. Stress, poor lifestyle, and poor health-seeking behaviour interplay with other factors like diet and exercise leading to poor control of diabetes and hypertension.

CONCLUSION

A better understanding of determinants associated with disease control can assist in designing focused patient outreach plans, customized communication strategies, need-based care delivery plans, and specific competency-based capacity-building models for health care workers. Patient-centric care focusing on biological, social and behavioural determinants is pivotal for appropriate management of NCDs at community level in low-middle income countries.

Health system challenges and opportunities in organizing non-communicable diseases services delivery at primary healthcare level in Bangladesh: A qualitative study

Introduction

The weak health system is viewed as a major systematic obstacle to address the rising burden of non-communicable diseases (NCDs) in resource-poor settings. There is little information about the health system challenges and opportunities in organizing NCD services. This study examined the health system challenges and opportunities in organizing NCD services for four major NCDs (cervical cancer, diabetes mellitus, cardiovascular diseases, and chronic respiratory illnesses) at the primary healthcare (PHC) level in Bangladesh.

Methods

Using a qualitative method, data were collected from May to October 2021 by conducting 15 in-depth interviews with local healthcare providers, 14 key informant interviews with facility-based providers and managers, and 16 focus group discussions with community members. Based on a health system dynamics framework, data were analyzed thematically. Information gathered through the methods and sources was triangulated to validate the data.

Results

Organization of NCD services at the PHC level was influenced by a wide range of health system factors, including the lack of using standard treatment guidelines and protocols, under-regulated informal and profit-based private healthcare sectors, poor health information system and record-keeping, and poor coordination across healthcare providers and platforms. Furthermore, the lack of functional referral services; inadequate medicine, diagnostic facilities, and logistics supply; and a large number of untrained human resources emerged as key weaknesses that affected the organization of NCD services. The availability of NCD-related policy documents, the vast network of healthcare infrastructure and frontline staff, and increased demand for NCD services were identified as the major opportunities.

Conclusion

Despite the substantial potential, the health system challenge impeded the organization of NCD services delivery at the PHC level. This weakness needs be to addressed to organize quality NCD services to better respond to the rising burden of NCDs at the PHC level.

Long-term cost-effectiveness of quality of diabetes care; experiences from private and public diabetes centers in Iran

BACKGROUND

The quality of health care has a significant impact on both patients and the health system in terms of long-term costs and health consequences. This study focuses on determining the long-term cost-effectiveness in quality of diabetes care in two different settings (private/public) using longitudinal patient-level data in Iran.

METHODS

By extracting patients intermediate biomedical markers in under-treatment type 2 diabetes patients(T2DP) in a longitudinal retrospective study and by applying the localized UKPDS diabetes model, lifetime health outcomes including life expectancy, quality-adjusted Life expectancy (QALE) and direct medical costs of managing disease and related complications from a healthcare system perspective was predicted. Costs and utility decrements had derived on under-treatment T2DP from 7 private and 8 Public diabetes centers. We applied two steps sampling mehods to recruit the needed sample size (cluster and random sampling). To cope with first and second-order uncertainty, we used Monte-Carlo simulation and bootstrapping techniques. Both cost and utility variables were discounted by 3% in the base model.

RESULTS

In a 20-year time horizon, according to over 5 years of quality of care data, outcomes-driven in the private sector will be more effective and more costly (5.17 vs. 4.95 QALE and 15,385 vs. 8092). The incremental cost-effectiveness ratio (ICER) was $33,148.02 per QALE gained, which was higher than the national threshold.

CONCLUSION

Although quality of care in private diabetes centers resulted in a slight increase in the life expectancy in T2DM patients, it is associated with unfavorable costs, too. Private-sector in management of T2DM patients, compared with public (governmental) diabetic Centers, is unlikely to be cost-effective in Iran.

Hypertension treatment cascade in India: results from National Noncommunicable Disease Monitoring Survey

Hypertension is a major risk factor for ischemic heart disease and stroke. We estimated prevalence, awareness, treatment, and control of hypertension along with its determinants in India. We used data from the National NCD Monitoring Survey-(NNMS-2017-2018) which studied one adult (18-69 years) from a representative sample of households across India and collected information on socio-demographic variables, risk factors for NCDs and treatment practices. Blood pressure was recorded digitally and hypertension was defined as systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg or currently on medications. Awareness was defined as being previously diagnosed with hypertension by a health professional; on treatment as taking a dose of medication once in the last 14 days and; control as SBP < 140 mmHg and DBP < 90 mmHg. Multivariate Logistic regression was performed to estimate determinants. Out of 10,593 adults with a blood pressure measurement (99.4%), 3017 (28.5%; 95% CI: 27.0-30.1) were found to have hypertension. Of these hypertensives, 840 (27.9%; 95% CI: 25.5-30.3) were aware, 438 (14.5%; 95% CI: 12.7-16.5) were under treatment and, 379 (12.6%; 95% CI: 11.0-14.3) were controlled. Significant determinants of awareness were being in the age group 50-69 years (aOR 2.45 95% CI: 1.63-3.69), women (1.63; 95% CI: 1.20-2.22) and from higher wealth quintiles. Those in the age group 50-69 (aOR 4.80; 95% CI: 1.74-13.27) were more likely to be under treatment. Hypertension control was poorer among urban participants (aOR 0.55; 95% CI: 0.33-0.90). Significant regional differences were noted, though without any clear trend. One-fifth of the patients were being managed at public facilities. The poor population-level hypertension control needs strengthening of hypertension services in the Universal Health Coverage package.

Improving access to medicines for non-communicable diseases in rural primary care: results from a quasi-randomized cluster trial in a district in South India

BACKGROUND

A large proportion of non-communicable diseases (NCDs) are treatable within primary health care (PHC) settings in a cost-effective manner. However, the utilization of PHCs for NCD care is comparatively low in India. The Access-to-Medicines (ATM) study examined whether (and how) interventions aimed at health service optimization alone or combined with community platform strengthening improve access to medicines at the primary health care level within the context of a local health system.

METHOD

A quasi-randomized cluster trial was used to assess the effectiveness of the intervention (18 months) implemented across 39 rural PHCs (clusters) of three sub-districts of Tumkur in southern India. The intervention was allocated randomly in a 1:1:1 sequence across PHCs and consisted of three arms: Arm A with a package of interventions aimed at health service delivery optimization; B for strengthening community platforms in addition to A; and the control arm. Group allocation was not blinded to providers and those who assessed outcomes. A household survey was used to understand health-seeking behaviour, access and out-of-pocket expenditure (OOP) on key anti-diabetic and anti-hypertension medicines among patients; facility surveys were used to assess the availability of medicines at PHCs. Primary outcomes of the study are the mean number of days of availability of antidiabetic and antihypertensive medicines at PHCs, the mean number of patients obtaining medicines from PHC and OOP expenses.

RESULT

The difference-in-difference estimate shows a statistically insignificant increase of 31.5 and 11.9 in mean days for diabetes and hypertension medicines availability respectively in the study arm A PHCs beyond the increase in the control arm. We further found that there was a statistically insignificant increase of 2.2 and 3.8 percentage points in the mean proportion of patients obtaining medicines from PHC in arm A and arm B respectively, beyond the increase in the control arm.

CONCLUSION

There were improvements in NCD medicine availability across PHCs, the number of patients accessing PHCs and reduction in OOP expenditure among patients, across the study arms as compared to the control arm; however, these differences were not statistically significant.

TRIAL REGISTRATION

Trial registration number CTRI/2015/03/005640 . This trial was registered on 17/03/2015 in the Clinical Trial Registry of India (CTRI) after PHCs were enrolled in the study (retrospectively registered). The CTRI is the nodal agency of the Indian Council of Medical Research for registration of all clinical, experimental, field intervention and observation studies.

Diabetes Care in India: A Descriptive Study

CONTEXT

Diabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent and reduce the risk of long-term complications. It requires an array of investigations to provide an accurate picture of the condition and its management accordingly by a qualified doctor.

AIMS

This study was conducted to understand the treatment received by type 2 diabetes (T2DM) patients from various categories of health care professionals and awareness about diabetes reversal by lifestyle modification and prevention of complications.

SETTINGS AND DESIGN

This was a community-based cross-sectional study.

SUBJECTS AND METHODS

The link of the semi-structured questionnaire in Google form with e-consent was sent to all members in the selected groups of "World free of obesity and diabetes" campaign on their personal WhatsApp account.

STATISTICAL ANALYSIS USED

A total of 3082 participants were included, and the data obtained were analyzed using SPSS v26.

RESULTS

The mean age of the participants was 50.26 ± 9.78 years ranging from 18 to 81 years. A total of 35.8% of the study population was diabetic for 1-5 years. A total of 54.9% were started with antidiabetic medication on the same day of diagnosis. Only 1.5% of the patients had complete investigation profile for T2DM, 50.2% of the patients were briefed about hypoglycemia, and only 15.8% of the patients were checked for retinopathy.

CONCLUSIONS

Most doctors, qualified as well as nonqualified, did not follow the standard guidelines for diagnosis, treatment, and patient education regarding T2DM; therefore, it is necessary to train all medical practitioners regarding these guidelines. Diabetes reversal by lifestyle modification must be prescribed as the first line of treatment in patients with T2DM.

Managing diabetes mellitus with comorbidities in primary healthcare facilities in urban settings: a qualitative study among physicians in Odisha, India

Aim

To explore the perceived barriers and facilitators in the management of the patients having diabetes with comorbidities by primary care physicians.

Methods

A qualitative In-Depth Interview study was conducted among the primary care physicians at seventeen urban primary health care centres at Bhubaneswar city of Odisha, India. The digitally recorded interviews were transcribed verbatim and translated into English. The data were analysed using thematic analysis.

Results

Barriers related to physicians, patients and health system were identified. Physicians felt lack of necessary knowledge and skills, communication skills and overburdening due to multiple responsibilities to be major barriers to quality care. Patients’ attitude and beliefs along with socio-economic status played an important role in treatment adherence and in the management of their disease conditions. Poor infrastructure, irregular medicine supply, and shortage of skilled allied health professionals were also found to be barriers to optimal care delivery, as was the lack of electronic medical records and personal treatment records.

Conclusion

Comprehensive guidelines with on the job training for capacity building of the physicians and creation of multidisciplinary teams at primary care level for a more holistic approach towards management of diabetes with comorbidities could be the way forward to optimal delivery of care.

Effectiveness of polyherbal formulations for the treatment of type 2 Diabetes mellitus - A systematic review and meta-analysis

Background

The mortality and morbidity rate of diabetes patients is increasing worldwide which requires an ideal treatment to prevent the disease worsening. Traditional medicine is gaining more attention in diabetes due to its efficacy and safety. We, therefore performed a systematic review study of clinical trials to assess the comparative effect of polyherbal formulations in type 2 Diabetes mellitus.

Objectives

To find the effectiveness of polyherbal formulations in blood sugar and lipid level for type 2 Diabetes mellitus.

Material and methods

PubMed, Scopus and CINAHL databases for clinical trials investigating the effect of polyherbal formulations in Type 2 Diabetes mellitus patients were searched. Meta-analysis of eligible trials was conducted employing Revman 5.2 software.

Results

Fourteen randomized controlled trials were found eligible for meta-analysis. Meta-analysis of findings showed a significant effect of polyherbal formulations on blood sugar level compared to control group. The estimated standard mean changes at 95% confidence interval, following polyherbal formulations treatment were −0.59, (−0.91 to – 0.27) mg/dL; for fasting blood sugar(p < 0.001), −0.69, (−1.18 to −0.21) mg/dL; for postprandial blood sugar (p = 0.005) and −0.46, (−0.88 to −0.04) gm%; for glycated haemoglobin (p = 0.03). The reduction in postprandial sugar and glycated haemoglobin was statistically significant with polyherbal formulations compared to metformin treatment but not for fasting sugar. Similarly in lipid profile the reduction for total cholesterol and triglycerides was statistically significant with polyherbal formulations compared to control group but was not significant for HDL and LDL whereas in other group of polyherbal formulations and metformin only HDL was favouring polyherbal formulations.

Conclusion

Polyherbal formulations occurred to be effective in lowering blood sugar level in Type 2 diabetes but their further efficacy in managing diabetes needs to be validated. Therefore, a qualitative, long term, randomized placebo-controlled trials of adequate sample size are necessary to determine the efficacy of polyherbal formulation in managing diabetes.

Improving primary care for diabetes and hypertension: findings from implementation research in rural South India

BACKGROUND

Chronic conditions are a leading cause of death and disability worldwide. Low-income and middle-income countries such as India bear a significant proportion of this global burden. Redesigning primary care from an acute-care model to a model that facilitates chronic care is a challenge and requires interventions at multiple levels.

OBJECTIVES

In this intervention study, we aimed to strengthen primary care for diabetes and hypertension at publicly funded primary healthcare centres (PHCs) in rural South India.

DESIGN AND METHODS

The complexities of transforming the delivery of primary care motivated us to use a 'theory of change' approach to design, implement and evaluate the interventions. We used both quantitative and qualitative data collection methods. Data from patient records regarding processes of care, glycaemic and blood pressure control, interviews with patients, observations and field notes were used to analyse what changes occurred and why.

INTERVENTIONS

We implemented the interventions for 9 months at three PHCs: (1) rationalise workflow to include essential tasks like counselling and measurement of blood pressure/blood glucose at each visit; (2) distribute clinical tasks among staff; (3) retain clinical records at the health facility and (4) capacity building of staff.

RESULTS

We found that interventions were implemented at all three PHCs for the first 4 months but did not continue at two of the PHCs. This fadeout was most likely the result of staff transfers and a doctor's reluctance to share tasks. The availability of an additional staff member in the role of a coordinator most likely influenced the relative success of implementation at one PHC.

CONCLUSION

These findings draw attention to the need for building teams in primary care for managing chronic conditions. The role of a coordinator emerged as an important consideration, as did the need for a stable core of staff to provide continuity of care.

A narrative review of gaps in the provision of integrated care for noncommunicable diseases in India

BACKGROUND

Low- and middle-income countries (LMICs) account for a higher burden of noncommunicable diseases (NCD) and home to a higher number of premature deaths (before age 70) from NCDs. NCDs have become an integral part of the global development agenda; hence, the scope of action on NCDs extends beyond just the health-related sustainable development goal (SDG 3). However, the organization and integration of NCD-related health services have faced several gaps in the LMIC regions such as India. Although the national NCD programme of India has been in operation for a decade, challenges remain in the integration of NCD services at primary care. In this paper, we have analysed existing gaps in the organization and integration of NCD services at primary care and suggested plausible solutions that exist.

METHOD

The identification of gaps is based out of a review of peer-reviewed articles, reports on national and global guidelines/protocols. The gaps are organized and narrated at four levels such as community, facility, health system, health policy and research, as per the WHO Innovative Care for Chronic Conditions framework (WHO ICCC).

RESULT

The review found that challenges in the identification of eligible beneficiaries, shortage and poor capacity of frontline health workers, poor functioning of community groups and poor community knowledge on NCD risk factors were key gaps at the community level. Challenges at facility level such as poor facility infrastructure, lack of provider knowledge on standards of NCD care and below par quality of care led to poor management of NCDs. At the health system level, we found, organization of care, programme management and monitoring systems were not geared up to address NCDs. Multi-sectoral collaboration and coordination were proposed at the policy level to tackle NCDs; however, gaps remained in implementation of such policies. Limited research on the effect of health promotion, prevention and, in particular, non-medical interventions on NCDs was found as a key gap at the research level.

CONCLUSION

This paper reinforces the need for an integrated comprehensive model of NCD care especially at primary health care level to address the growing burden of these diseases. This overarching review is quite relevant and useful in organizing NCD care in Indian and similar LMIC settings.

Economic Impact of Diabetes in South Asia: the Magnitude of the Problem

PURPOSE OF REVIEW

To critically assess and identify gaps in the current literature on the economic impact of diabetes in South Asia.

RECENT FINDINGS

The total annual (direct medical and non-medical and indirect) costs for diabetes care in South Asia range from $483-$2637 per patient, and on an average 5.8% of patients with diabetes suffer catastrophic spending i.e. when households reduce basic expenditure by 40% to cope with healthcare costs. The mean direct costs per patient are positively associated with a country's gross domestic product (GDP) per capita, although there is wide heterogeneity across South Asian countries. With an estimated 84 million people suffering from diabetes in South Asia, diabetes imposes a substantial economic burden on individuals, families, and society. Since the disease burden increasingly occurs in the most productive midlife period, it adversely affects workforce productivity and macroeconomic development. Diabetes-related complications lead to markedly higher treatment costs, causing catastrophic medical spending for many households, thus underscoring the importance of preventing diabetes-related complications.

"The number of clients is increasing but the supplies are reducing": provider strategies for responding to chronic antiretroviral (ARV) medicines stock-outs in resource-limited settings: a qualitative study from Uganda

Background

Despite the increasing frequency of ARV medicines stock-outs in Sub-Saharan Africa, there is little research inquiring into the mitigation strategies devised by frontline health facilities. Many previous studies have focused on ‘upstream’ or national-level drivers of ARVs stock-outs with less empirical attention devoted ‘down-stream’ or at the facility-level. The objective of this study was to examine the strategies devised by health facilities in Uganda to respond to the chronic stock-outs of ARVs.

Methods

This was a qualitative research design nested within a larger mixed-methods study. We purposively selected 16 health facilities from across Uganda (to achieve diversity with regard to; level of care (primary/ tertiary), setting (rural/urban) and geographic sub-region (northern/ central/western). We conducted 76 Semi-structured interviews with ART clinic managers, clinicians and pharmacists in the selected health facilities supplemented by on-site observations and documentary reviews. Data were analyzed by coding and thematic analyses.

Results

Participants reported that facility-level contributors to stock-outs include untimely orders of drugs from suppliers and inaccurate quantification of ARV medicine needs due to a paucity of ART program data. Internal stock management solutions for mitigating stock-outs which emerged include the substitution of ARV medicines which were out of stock, overstocking selected medicines and the use of recently expired drugs. The external solutions for mitigating stock-outs which were identified include ‘borrowing’ of ARVs from peer-providers, re-distributing stock across regions and upward referrals of patients. Systemic drivers of stock-outs were identified. These include the supply of drugs with a short shelf life, oversupply and undersupply of ARV medicines and migration pressures on the available ARVs stock at case-study facilities.

Conclusion

Health facilities devised internal stock management strategies and relied on peer-provider networks for ARV medicines during stock-out events. Our study underscores the importance of devising interventions aimed at improving Uganda’s medicines supply chain systems in the quest to reduce the frequency of ARV medicines stock-outs at the front-line level of service delivery. Further research is recommended on the effect of substituting ARV medicines on patient outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4137-7) contains supplementary material, which is available to authorized users.

Designing a comprehensive Non-Communicable Diseases (NCD) programme for hypertension and diabetes at primary health care level: evidence and experience from urban Karnataka, South India

BACKGROUND

India accounts for more than two-third of mortality due to non-communicable diseases (NCDs) in south-east Asia. The burden is high in Karnataka, one of the largest states in southern India. There is a need for integration of disease prevention, health promotion, treatment and care within the national program at primary level. A public-private partnership initiative explored evidence gaps to inform a health system based, integrated NCD programme across care continuum with a focus on hypertension and diabetes.

METHODS

The study was conducted during 2017-18 in urban parts of Mysore city, covering a population of 58,000. Mixed methods were used in the study; a population-based screening to estimate denominators for those with disease and at risk; cross-sectional surveys to understand distribution of risk factors, treatment adherence and out of pocket expenses; facility audits to assess readiness of public and private facilities; in-depth interviews and focus group discussions to understand practices, myths and perceptions in the community. Chi-square tests were used to test differences between the groups. Framework analysis approach was used for qualitative analysis.

RESULTS

Twelve and 19% of the adult population had raised blood sugar and blood pressure, respectively, which increased with age, to 32 and 44% for over 50 years. 11% reported tobacco consumption; 5.5%, high alcohol consumption; 40%, inadequate physical activity and 81%, inappropriate diet consumption. These correlated strongly with elderly age and poor education. The public facilities lacked diagnostics and specialist services; care in the private sector was expensive. Qualitative data revealed fears and cultural myths that affected treatment adherence. The results informed intervention design across the NCD care continuum.

CONCLUSIONS

The study provides tools and methodology to gather evidence in designing comprehensive NCD programmes in low and middle income settings. The study also provides important insights into public-private partnership driving effective NCD care at primary care level.

Challenges in primary care for diabetes and hypertension: an observational study of the Kolar district in rural India

Background

Chronic diseases have emerged as the leading cause of death globally, and 20% of Indians are estimated to suffer from a chronic condition. Care for chronic diseases poses a major public health challenge, especially when health care delivery has been geared traditionally towards acute care. In this study, we aimed to better understand how primary care for diabetes and hypertension is currently organised in first-line health facilities in rural India, and propose evidence-based ways forward for strengthening local health systems to address chronic problems.

Methods

We used qualitative and quantitative methods to gain insight into how care is organised and how patients and providers manage within this delivery system. We conducted in-depth interviews with the medical doctors working in three private clinics and in three public primary health centres. We also interviewed 24 patients with chronic diseases receiving care in the two sub-sectors. Non-participant observations and facility assessments were performed to triangulate the findings from the interviews.

Results

The current delivery system has many problems impeding the delivery of quality care for chronic conditions. In both the public and private facilities studied, the care processes are very doctor-centred, with little room for other health centre staff. Doctors face very high workloads, especially in the public sector, jeopardising proper communication with patients and adequate counselling. In addition, the health information system is fragmented and provides little or no support for patient follow-up and self-management. The patient is largely left on their own in trying to make sense of their condition and in finding their way in a complex and scattered health care landscape.

Conclusions

The design and organisation of care for persons with chronic diseases in India needs to be rethought. More space and responsibility should be given to the primary care level, and relatively less to the more specialised hospital level. Furthermore, doctors should consider delegating some of their tasks to other staff in the first-line health facility to significantly reduce their workload and increase time available for communication. The health information system needs to be adapted to better ensure continuity of care and support self-management by patients.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3876-9) contains supplementary material, which is available to authorized users.

Models of care for chronic conditions in low/middle-income countries: a 'best fit' framework synthesis

Management of chronic conditions is a challenge for healthcare delivery systems world over and especially for low/middle-income countries (LMIC). Redesigning primary care to deliver quality care for chronic conditions is a need of the hour. However, much of the literature is from the experience of high-income countries. We conducted a synthesis of qualitative findings regarding care for chronic conditions at primary care facilities in LMICs. The themes identified were used to adapt the existing chronic care model (CCM) for application in an LMIC using the ‘best fit’ framework synthesis methodology. Primary qualitative research studies were systematically searched and coded using themes of the CCM. The results that could not be coded were thematically analysed to generate themes to enrich the model. Search strategy keywords were: primary health care, diabetes mellitus type 2, hypertension, chronic disease, developing countries, low, middle-income countries and LMIC country names as classified by the World Bank. The search yielded 404 articles, 338 were excluded after reviewing abstracts. Further, 42 articles were excluded based on criteria. Twenty-four studies were included for analysis. All themes of the CCM, identified a priori, were represented in primary studies. Four additional themes for the model were identified: a focus on the quality of communication between health professionals and patients, availability of essential medicines, diagnostics and trained personnel at decentralised levels of healthcare, and mechanisms for coordination between healthcare providers. We recommend including these in the CCM to make it relevant for application in an LMIC.

Clinical management of type 2 diabetes in south Asia

Compared with other ethnic groups, south Asian people with type 2 diabetes tend to develop the disease at a younger age and manifest with higher glycaemia, dyslipidaemia, nephropathy, and cardiovascular diseases. Additionally, specific issues that can affect treatment of type 2 diabetes in south Asia include poor awareness of the disease, delay in diagnosis, inadequate treatment, the use of ineffective and often harmful alternative medicines, and frequent non-compliance with lifestyle recommendations and drug treatment. Disease development at younger ages, delayed diagnosis, and inadequate management result in early development of severe complications and premature mortality. In this Series paper, we describe the challenges associated with the increasing burden of type 2 diabetes in south Asia and discuss ways to improve clinical care of people with the disorder in the region (defined to include Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka). Treatment of diabetes in south Asia needs to be individualised on the basis of diverse and heterogeneous lifestyle, phenotype, environmental, social, cultural, and economic factors. Aggressive management of risk factors from diagnosis is necessary to reduce the risk of microvascular and macrovascular complications, focusing on provision of basic treatments (eg, metformin, low-cost statins, and blood pressure-lowering drugs) and other interventions such as smoking cessation. Strengthening of the primary care model of care, better referral linkages, and implementation of rehabilitation services to care for patients with chronic complications will be important. Finally, improvement of physicians' skills, provision of relevant training to non-physician health-care workers, and the development and regular updating of national clinical management guidelines will also be crucial to improve diabetes care in the region.

Undernutrition, obesity and governance: a unified framework for upholding the right to food

This paper addresses the need for conceptual and analytic clarity on nutrition governance, an essential underpinning of more effective approaches for undernutrition, the 'single greatest constraint to global development' and obesity, which already accounts for 4% of the world's disease burden and is growing rapidly. The governance of nutrition, which is essential to designing and implementing policies to realise the right to food, is among the most important and most defining duties of society. But research and action on nutrition governance are hampered by the absence of conceptual rigour, even as the continuing very high burden of undernutrition and the rapid rise in obesity highlight the need for such structures. The breadth of nutrition itself suggests that governance is both needed and sure to be complicated. This analysis explores the reasons attention has come to governance in development policy making, and why it has focused on nutrition governance in particular. It then assesses how the concept of nutrition governance has been used, finding that it has become increasingly prominent in scholarship on poor nutritional outcomes, but remains weakly specified and is invoked by different authors to mean different things. Undernutrition analysts have stressed coordination problems and structural issues related to the general functioning of government. Those studying obesity have emphasised international trade policies, regulatory issues and corporate behaviour. This paper argues that the lack of a clear, operational definition of governance is a serious obstacle to conceptualising and solving major problems in nutrition. To address this need, it develops a unified definition of nutrition governance consisting of three principles: accountability, participation and responsiveness. These are justified with reference to the social contract that defines modern nations and identifies citizens as the ultimate source of national power and legitimacy. A unified framework is then employed to explore solutions to nutrition governance problems.

Understanding the dynamic interactions driving the sustainability of ART scale-up implementation in Uganda

Background

Despite increasing recognition that health-systems constraints are the fundamental barrier to attaining anti-retroviral therapy (ART) scale-up targets in Sub-Saharan Africa, current discourses are dominated by a focus on financial sustainability. Utilizing the health system dynamics framework, this study aimed to explore the interactions in health system components and their influence on the sustainability of ART scale-up implementation in Uganda.

Methods

This study entailed qualitative organizational case-studies within a two-phased mixed-methods sequential explanatory research design. In Phase One, a survey of 195 health facilities across Uganda which commenced ART services between 2004 and 2009 was conducted. In Phase Two, six health facilities were purposively selected for in-depth examination involving i) In-depth interviews (n = 44) ii) and semi-structured interviews (n = 35). Qualitative data was analyzed by coding and thematic analysis. Descriptive statistics were managed in STATA (v 13).

Results

Five dynamic interactions in ART program sustainability drivers were identified; i) Failure to update basic ART program records contributed to chronic ART medicines stock-outs ii) Health workforce shortages and escalating patient volumes prompted adaptations in ART service delivery models iii) Broader governance issues manifested in poor road networks undermined ART medicines supply chains iv) Sustained financing for ART programs was influenced by external donors v) The values associated with the ownership-type of a health facility affected ART service delivery and coverage.

Conclusion

The sustainability of ART programs at the facility-level in Uganda is a function of a complex interaction in elements of the health system and must be understood beyond sustaining international funding for ART scale-up.

Diabetic retinopathy screening programme utilising non-mydriatic fundus imaging in slum populations of New Delhi, India

OBJECTIVES

To develop and implement a community-based programme for screening of diabetic retinopathy (DR) in urban populations of Delhi.

METHODS

Known diabetics (KDs) aged 40 years and older were identified through house-to-house surveys, volunteers and publicity. All KDs were referred to DR screening camps organised locally where procedures included brief medical history, ocular examination and non-mydriatic fundus photography using portable handheld camera. Fundal images were graded on the spot by trained optometrists for DR. Patients with DR were referred to tertiary centre for management.

RESULTS

A total of 11 566 KDs were identified, of whom 9435 (81.6%) visited DR screening camps and 8432 (89.4%) had DR gradable images. DR was identified in 13.5% of subjects; 351 cases were mild NPDR, 567 moderate, 92 severe. Seventy-seven had PDR, and 49 had DME, and 2.7% of participants were blind (presenting visual acuity <3/60 in better eye). Non-use of lifestyle management, presence of systemic complications, BMI <18.5 kg/m² , disease duration of >5 years and uncontrolled diabetes were associated with increased odds of DR. All cases with DR were referred, and 420 (37%) successful referrals to base hospital were observed.

CONCLUSION

The programme of creating awareness about DR, identifying KDs and optometrist-led DR screening using non-mydriatic fundus camera based in slums was successful.

Prevalence and pattern of co morbidity among type2 diabetics attending urban primary healthcare centers at Bhubaneswar (India)

OBJECTIVE

India has the second largest diabetic population in the world. The chronic nature of the disease and high prevalence of co-existing chronic medical conditions or "co morbidities" makes diabetes management complex for the patient and for health care providers. Hence a strong need was felt to explore the problem of co morbidity among diabetics and its dimensions in primary health care practices.

METHOD

This cross sectional survey was carried out on 912 type 2 diabetes patients attending different urban primary health care facilities at Bhubaneswar. Data regarding existence of co morbidity and demographical details were elicited by a predesigned, pretested questionnaire"Diabetes Co morbidity Evaluation Tool in Primary Care (DCET- PC)". Statistical analyses were done using STATA.

RESULTS

Overall 84% had one ormore than one comorbid condition. The most frequent co morbid conditions were hypertension [62%], acid peptic disease [28%], chronic back ache [22%] and osteoarthritis [21%]. The median number of co morbid conditions among both males and females is 2[IQR = 2]. The range of the number of co morbid conditions was wider among males [0-14] than females [0-6]. The number of co morbidities was highest in the age group > = 60 across both sexes. Most of the male patients below 40 years of age had either single [53%] or three co morbidities [11%] whereas among female patients of the same age group single [40%] or two co morbidities [22%] were more predominantly present. Age was found to be a strong independent predictor for diabetes co morbidity. The odds of having co morbidity among people above poverty line and schedule caste were found to be[OR = 3.50; 95%CI 1.85-6.62]and [OR = 2.46; CI 95%1.16-5.25] respectively. Odds were increased for retired status [OR = 1.21; 95% CI 1.01-3.91] and obesity [OR = 3.96; 95%CI 1.01-15.76].

CONCLUSION

The results show a high prevalence of co morbidities in patients with type 2 diabetes attending urban primary health care facilities. Hypertension, acid peptic disease, chronic back ache and arthritis being the most common, strategies need to be designed taking into account the multiple demands of co morbidities.

Health inequalities in hypertension and diabetes management among the poor in urban areas: a population survey analysis in south Korea

BACKGROUND

This study investigated whether the prevalence, awareness, treatment, and control of hypertension and diabetes differed by residential areas. In addition, the rate of good hypertension or diabetes control was examined separately in men and women, and in urban and rural areas.

METHODS

This study used Korea National Health and Nutrition Examination V (2010-2012) data, a nationwide cross-sectional survey of general South Korean population. Residential areas were categorized into urban and rural areas. To examine differences between the residential areas in terms of prevalence, awareness, treatment, and control of hypertension and diabetes we performed a multivariate logistic regression adjusting for age, body mass index, physical activity, alcohol use, smoking, marital status, monthly income, and educational level. To investigate control of hypertension or diabetes within each residential area, we performed a subgroup analysis in both urban and rural areas.

RESULTS

The prevalence of hypertension is higher among men in urban areas than among those in rural areas (OR = 0.80; 95 % CI = 0.67-0.96, reference group = urban areas). However, the subgroups did not differ in terms of diabetes prevalence, awareness, treatment, and control. Regardless of both sex and residential area, participants in good control of their hypertension and diabetes were younger. Inequality in good control of hypertension was observed in men who lived in urban (≤Elementary school, OR 0.74, 95 % CI 0.60-0.92) and rural areas (≤Elementary school, OR 0.67, 95 % CI 0.46-0.99). Inequality in health status was found in women who resided in urban areas (≤Elementary school, OR 0.53, 95 % CI 0.37-0.75). Good control of diabetes also showed inequalities in health status for both men (≤Elementary school, OR 0.61, 95 % CI 0.40-0.94; Middle/High school, OR 0.69, 95 % CI 0.49-0.96) and women in urban areas (≤1 million won, OR 0.56, 95 % CI 0.33-0.93) (Reference group = '≥College' for education and '>3 million' Korean won for income).

CONCLUSIONS

After correction for individual socioeconomic status, differences by residential area were not observed. However, when the participants with good disease control were divided by region, inequality was confirmed in urban residents. Therefore, differentiated health policies to resolve individual and regional health inequalities are necessary.

Adherence to diabetes care processes at general practices in the National Capital Region-Delhi, India

AIM

To assess the level of adherence to diabetes care processes, and associated clinic and patient factors at general practices in Delhi, India.

METHODS

We interviewed physicians (n = 23) and patients with diabetes (n = 406), and reviewed patient charts at general practices (government = 5; private = 18). We examined diabetes care processes, specifically measurement of weight, blood pressure (BP), glycated hemoglobin (HbA1c), lipids, electrocardiogram, dilated eye, and a foot examination in the last one year. We analyzed clinic and patient factors associated with a number of care processes achieved using multilevel Poisson regression model.

RESULTS

The average number of clinic visits per patient was 8.8/year (standard deviation = 5.7), and physicians had access to patient's previous records in only 19.7% of patients. Dilated eye exam, foot exam, and electrocardiogram were completed in 7.4%, 15.1%, and 29.1% of patients, respectively. An estimated 51.7%, 88.4%, and 28.1% had ≥1 measurement of HbA1c, BP, and lipids, respectively. Private clinics, physician access to patient's previous records, use of nonphysicians, patient education, and the presence of diabetes complication were positively associated with a number of care processes in the multivariable model.

CONCLUSION

Adherence to diabetes care processes was suboptimal. Encouraging implementation of quality improvement strategies like Chronic Care Model elements at general practices may improve diabetes care.

Managing non-communicable diseases at health district level in Cambodia: a systems analysis and suggestions for improvement

Background

Cambodia developed its public health system along the principles of the district model and geared its services towards managing communicable diseases and maternal and child health issues. In line with other countries in the region, non-communicable diseases have emerged as a leading cause of adult mortality. We assessed the current capacity of the Cambodian district health system to manage hypertension and diabetes, with a focus on access to medicine for these chronic conditions.

Methods

A case study whereby in three purposely selected districts in an equal number of provinces a total of 74 informants were interviewed: 27 health care providers and administrators, 30 community representatives and 17 managers of specific non-communicable diseases interventions and social health protection schemes. Questions related to the World Health Organization’s health system building blocks. Data analysis involved coding, indexing, charting and mapping the data. Following these exercises all information was analysed by kind of respondent and their respective answer to the question concerned. Responses by respondents of three groups of interviewees were compared when appropriate. At 14 health centres and 3 district hospitals the availability of key medicines for hypertension and diabetes in accordance with the National Essential Drug List was assessed. This was also done for essential tools and equipment to diagnose these two conditions.

Results

Although there was agreement amongst nearly all interviewees that non-communicable diseases were prevalent, the district health system, including all health systems building blocks and the referral system, was inadequately developed to effectively deal with these conditions. Medicines supply was erratic and the quantity provided allowed for few patients to be treated, for a short period only, mainly at secondary or tertiary level.

Conclusions

Because of the public health, social and economic importance of non-communicable diseases, a rapid response is required. Given the current Cambodian situation, such response may initially be a diagonal approach, with non-communicable diseases services integrated in the National HIV/AIDS Programme. This should happen together with a reorientation of the health system to enable a horizontal approach to non-communicable diseases management in the long term.

Intervening in the local health system to improve diabetes care: lessons from a health service experiment in a poor urban neighborhood in India

BACKGROUND

Many efficacious health service interventions to improve diabetes care are known. However, there is little evidence on whether such interventions are effective while delivered in real-world resource-constrained settings.

OBJECTIVE

To evaluate an intervention aimed at improving diabetes care using the RE-AIM (reach, efficacy/effectiveness, adoption, implementation, and maintenance) framework.

DESIGN

A quasi-experimental study was conducted in a poor urban neighborhood in South India. Four health facilities delivered the intervention (n=163 diabetes patients) and the four matched facilities served as control (n=154). The intervention included provision of culturally appropriate education to diabetes patients, use of generic medications, and standard treatment guidelines for diabetes management. Patients were surveyed before and after the 6-month intervention period. We did field observations and interviews with the doctors at the intervention facilities. Quantitative data were used to assess the reach of the intervention and its effectiveness on patients' knowledge, practice, healthcare expenditure, and glycemic control through a difference-in-differences analysis. Qualitative data were analyzed thematically to understand adoption, implementation, and maintenance of the intervention.

RESULTS

Reach: Of those who visited intervention facilities, 52.3% were exposed to the education component and only 7.2% were prescribed generic medications. The doctors rarely used the standard treatment guidelines for diabetes management.

EFFECTIVENESS

The intervention did not have a statistically and clinically significant impact on the knowledge, healthcare expenditure, or glycemic control of the patients, with marginal reduction in their practice score. Adoption: All the facilities adopted the education component, while all but one facility adopted the prescription of generic medications.

IMPLEMENTATION

There was poor implementation of the intervention, particularly with regard to the use of generic medications and the standard treatment guidelines. Doctors' concerns about the efficacy, quality, availability, and acceptability by patients of generic medications explained limited prescriptions of generic medications. The patients' perception that ailments should be treated through medications limited the use of non-medical management by the doctors in early stages of diabetes. The other reason for the limited use of the standard treatment guidelines was that these doctors mainly provided follow-up care to patients who were previously put on a given treatment plan by specialists. Maintenance: The intervention facilities continued using posters and television monitors for health education after the intervention period. The use of generic medications and standard treatment guidelines for diabetes management remained very limited.

CONCLUSIONS

Implementing efficacious health service intervention in a real-world resource-constrained setting is challenging and may not prove effective in improving patient outcomes. Interventions need to consider patients' and healthcare providers' experiences and perceptions and how macro-level policies translate into practice within local health systems.

Barriers to Point-of-Care Testing in India: Results from Qualitative Research across Different Settings, Users and Major Diseases

BACKGROUND

Successful point-of-care testing, namely ensuring the completion of the test and treat cycle in the same encounter, has immense potential to reduce diagnostic and treatment delays, and impact patient outcomes. However, having rapid tests is not enough, as many barriers may prevent their successful implementation in point-of-care testing programs. Qualitative research on diagnostic practices may help identify such barriers across different points of care in health systems.

METHODS

In this exploratory qualitative study, we conducted 78 semi-structured interviews and 13 focus group discussions in an urban and rural area of Karnataka, India, with healthcare providers (doctors, nurses, specialists, traditional healers, and informal providers), patients, community health workers, test manufacturers, laboratory technicians, program managers and policy-makers. Participants were purposively sampled to represent settings of hospitals, peripheral labs, clinics, communities and homes, in both the public and private sectors.

RESULTS

In the Indian context, the onus is on the patient to ensure successful point-of-care testing across homes, clinics, labs and hospitals, amidst uncoordinated providers with divergent and often competing practices, in settings lacking material, money and human resources. We identified three overarching themes affecting point-of-care testing: the main theme is 'relationships' among providers and between providers and patients, influenced by the cross-cutting theme of 'infrastructure'. Challenges with both result in 'modified practices' often favouring empirical (symptomatic) treatment over treatment guided by testing.

CONCLUSIONS

Even if tests can be conducted on the spot and infrastructure challenges have been resolved, relationships among providers and between patients and providers are crucial for successful point-of-care testing. Furthermore, these barriers do not act in isolation, but are interlinked and need to be examined as such. Also, a test alone has only limited power to overcome those difficulties. Test developers, policy-makers, healthcare providers and funders need to use these insights in overcoming barriers to point-of-care testing programs.