Damm Sokkor! : identifying, exploring and testing the factors influencing the care of patients with diabetes in primary care inTunisia

Abstract

Background Quality of diabetes care is variable and sub-optimal worldwide. Few studies have been undertaken in the developing world to identify factors that influence care. Objectives To identify, explore and test the patient, health professional and organisational factors associated with the quality of care of patients with diabetes in primary care in Tunisia. Methods A multi-method study within an ethnographic framework. Qualitative methods include participant observation, semi-structured interviews and focus groups with health professionals and patients with diabetes. Content and ethnographic analyses were undertaken. Quantitative data were collected from a random sample of medical records of patients with diabetes from a nationwide sample of 48 randomly-selected health centres. Multivariate regression analyses were undertaken to identify associations with fifteen quality indicators and 57 potential explanatory factors. Results The mean age of the study population (n=2160) was 62.4years, mean duration of diabetes 8.4years, 62% were female and 94% had type 2 diabetes. The standard of care varied but some improvements were apparent since 2000. The three most important factors to emerge from the qualitative data were also significantly and independently associated with higher quality of care: availability of medication, clinician motivation and chronic disease clinics. Other important factors were financial, gender and adherence issues. The predominant theme that emerged from the ethnographic analysis was the perception that access to medication at the health centre is "the only thing that matters". Conclusion This study has provided a detailed, unique picture of diabetes care in primary care from a low/middle income country. Important themes that need to be addressed in order to successfully implement culturally-appropriate, quality improvement interventions are accessibility to medications, clinician motivation, patients' health beliefs and gender issues. It is recommended that strategies, such as the development of the role of paramedical staff, be implemented within the context of culturally-adaptable national programs.