Collaborative practice in type 2 diabetes management in a developing country: A qualitative study of perceptions and attitudes of key stakeholders.

AIMS AND OBJECTIVES: To explore collaborative practice and perceptions and attitudes of key stakeholders on collaboration in type 2 diabetes management in a tertiary care setting. BACKGROUND: Understanding collaborative practice in diabetes care in developing countries helps to design and provide patient-centred and cost-effective care. DESIGN: An exploratory qualitative study. METHODS: Interviews were undertaken with 30 patients and 18 health professionals and policymakers. Thematic data analysis was undertaken to explore collaborative practice and examine participant perspectives on collaboration in diabetes management. We compared the findings with D'Amour's Collaboration Framework to determine the level of collaboration. RESULTS: Most participants reported a lack of collaborative practice in diabetes management, while they appreciated its importance in improving care. Perceptions varied with respect to what constituted collaborative practice. Three themes were identified: (1) perspectives of key stakeholders on current practice of collaboration; (2) impediments to collaborative practice; (3) strategies to improve collaborative practice. Analyses of the themes using D'Amour's Collaboration Framework indicated a low level of collaboration among physicians, nurses, pharmacists and policymakers, which was attributed to workload and time pressures on health professionals, power dynamics and lack of role clarity of all actors in collaborative action. Participants commented on the need to improve collaboration by establishing strong leadership and governance at different healthcare structure levels, which is committed to coordinating collaboration and developing collaborative frameworks and policies that guide collaborative undertaking. CONCLUSIONS: Perceived shortcomings of collaboration were attributed to inadequate resources, power dynamics, a lack of strong team functioning and policies. Participants' positive perceptions provide an opportunity to improve collaborative practice through incorporation of collaborative frameworks and policies. RELEVANCE TO CLINICAL PRACTICE: The findings in this study inform development of tailored and patient-centred diabetes care in tertiary care settings in sub-Saharan Africa. REPORTING METHOD: The study was reported in accordance with the COREQ checklist. PATIENT OR PUBLIC CONTRIBUTION: Patients or the public were not involved in the design, analysis or interpretation of the data in this study. However, patients and healthcare providers participated in pilot interviews, which helped refine the interview guides. The summary of the findings of the study was also discussed with patients and healthcare providers, where they provided feedback.

Patient-Centered Care Experiences of First-Generation, South Asian Migrants with Chronic Diseases Living in High-Income, Western Countries: Systematic Review.

Background: First-generation migrants from South Asia account for a considerable proportion of the immigrant populations in high-income, western countries and are at a high risk of developing complex, chronic diseases such as cardiovascular disease and diabetes. Yet, previous systematic reviews have not synthesized information about the healthcare needs and preferences of such migrants and the best ways for health services to provide them with appropriate, culturally sensitive, patient-centered care. The aim of this study is to systematically review the international evidence about first-generation, South Asian migrants' healthcare experiences from the patients' perspectives. Methods: Five databases were searched for qualitative, quantitative, and mixed methods studies published between January 1990 and April 2020. Fourteen thousand, six hundred and forty-four papers were retrieved and screened using pre-determined eligibility criteria. Sixty-one papers were included in this narrative synthesis. Relevant qualitative findings from the included papers were thematically analyzed, and quantitative findings were summarized. Results: Five themes emerged from findings: 1) Healthcare services engaged; 2) the language barrier; 3) experiences and perceptions of healthcare advice; 4) the doctor-patient relationship; and 5) the role of patients' families in supporting access and delivery of healthcare. Conclusion: The findings indicate that communication barriers reduce the cultural and linguistic appropriateness of healthcare. Potential solutions include employing healthcare staff from the same cultural background, training healthcare professionals in cultural competence, and proactively including first-generation, South Asian migrants in decision-making about their healthcare. Future research should explore South Asian migrants' experiences of multimorbidity management, continuity of care, interdisciplinary collaboration, the formation of treatment plans and goals as little to no data were available about these issues.

Current practices and future preferences of type 2 diabetes care in Ethiopia: A qualitative study on the perspectives of patients, health professionals, and policymakers.

BACKGROUND AND AIMS: This study aimed to examine perspectives of patients, health professionals, and policymakers on current practices and their future preferences for type 2 diabetes care in a tertiary hospital in Ethiopia. METHODS: An exploratory qualitative study was undertaken through interviews and focus groups with patients, health professionals, and policymakers. The participants were purposively sampled. Thematic analysis was undertaken. RESULTS: Fifty-nine participants were involved in the study. Participants' perspectives on current practices and future preferences comprised three themes: organisation of type 2 diabetes care delivery and infrastructure; continuity of care; and structured diabetes education. The current organisation comprised physicians, such as endocrinologists and endocrinology fellows, and nurses. Some nurses received training on diabetes foot and diabetic eye, which enabled patients to receive diabetes foot and diabetic eye care, respectively. The hospital lacked essential resources, such as medications, laboratory and diagnostic services, and diabetes educators, which hindered patient-centred care. Patients complained that the physical set-up at the hospital was not conducive to their privacy during consultations. Participants reported infrequent patient follow-up and monitoring, which contributed to uncontrolled diabetes. Future preferences involved access to essential resources and comprehensive diabetes care, such as structured diabetes education for improved patient outcomes. Participants sought out the development of tailored and context-specific diabetes management approaches that could meet specific patient needs and preferences. CONCLUSIONS: The findings have implications for designing patient-centred diabetes care tailored to the hospital's context and key stakeholders' preferences. This tailoring requires strong leadership to ensure availability of essential resources.

Development of a Complex Intervention for Effective Management of Type 2 Diabetes in a Developing Country.

There has been little focus on designing tailored diabetes management strategies in developing countries. The aim of this study is to develop a theory-driven, tailored and context-specific complex intervention for the effective management of type 2 diabetes at a tertiary care setting of a developing country. We conducted interviews and focus groups with patients, health professionals, and policymakers and undertook thematic analysis to identify gaps in diabetes management. The results of our previously completed systematic review informed data collection. We used the United Kingdom Medical Research Council framework to guide the development of the intervention. Results comprised 48 interviews, two focus groups with 11 participants and three co-design panels with 24 participants. We identified a lack of structured type 2 diabetes education, counselling, and collaborative care of type 2 diabetes. Through triangulation of the evidence obtained from data collection, we developed an intervention called VICKY (patient-centred collaborative care and structured diabetes education and counselling) for effective management of type 2 diabetes. VICKY comprised five components: (1) patient-centred collaborative care; (2) referral system for patients across transitions of care between different health professionals of the diabetes care team; (3) tools for the provision of collaborative care and documentation of care; (4) diabetes education and counselling by trained diabetes educators; and (5) contextualised diabetes education curriculum, educational materials, and documentation tools for diabetes education and counselling. Implementation of the intervention may help to promote evidence-based, patient-centred, and contextualised diabetes care for improved patient outcomes in a developing country.

Glycemic control among ambulatory type 2 diabetes patients with hypertension Co-morbidity in a developing country: A cross sectional study.

BACKGROUND: Achieving target blood glucose in type 2 diabetes patients with hypertension remains a challenge despite the availability of different classes of drugs to treat these conditions. OBJECTIVE: to assess the level of glycemic control and identify associated factors among ambulatory type 2 diabetes patients with hypertension co-morbidity. METHODS: We conducted a hospital based cross-sectional study from April 4 to May 11, 2016 among ambulatory type 2 diabetes patients with hypertension comorbidity at Jimma University Medical Center. We collected data on patient demographics, diabetes complications, and treatments using pretested questionnaire and data extraction format from a total of 300 eligible patients. We included consecutive patients that visited the hospital during the study period. We performed statistical analysis using SPSS version 21. Logistic regression analyses were done to identify the factors associated with poor glycemic control. P-value <0.05 was considered statistically significant. RESULTS: The majority of patients (60%) had poor glycemic control. The mean (SD) fasting blood glucose level over three consecutive months was 152.5 (65.7) mg/dl. Factors associated with poor glycemic control were age 41-60 years (AOR = 3.05, 95%CI: 1.20-7.77), age older than 60 years (AOR = 2.62, 95%CI: 1.01-6.80), presence of drug related problems (AOR = 2.29, 95%CI: 1.20-4.39), and low adherence to medications (AOR = 4.26, 95%CI: 1.70-10.65). CONCLUSION: The prevalence of poor glycemic control among ambulatory type 2 diabetes patients with hypertension comorbidity was high.

Prevalence and management practice of first generation antipsychotics induced side effects among schizophrenic patients at Amanuel Mental Specialized Hospital, central Ethiopia: cross-sectional study.

BACKGROUND: First-generation antipsychotics (FGAs) are associated with a range of adverse events which can significantly reduce patients' quality of life and contribute to non-adherence. The aim of this study was to assess the prevalence and management practice of first generation antipsychotics induced side effects among schizophrenic patients. METHODS: The study was conducted at Amanuel Mental Specialized Hospital from March to June, 2017. Data from patients were collected using a pretested structured questionnaire. Demographics and side effects of antipsychotics were collected by face to face interview. Clinical characteristics, medications and previous history of adverse drug events were extracted from medical records using data abstraction format. The data were analyzed using statistical software for social sciences (SPSS) version 20. Descriptive statistics and chi-square tests were done. Statistical significance was considered at p < 0.05. RESULTS: Out of 356 participants, 300 of them had complete data and were included in the study. The mean age of participants was 33.71 ± 10.2 years. The majority, 195(65.0%), of participants were males. Most of the participants, 293(97.7%), developed FGA medication induced side effects. One hundred sixty three (54.3%) participants were treated with Trihexyphenidyl for FGAs induced side effects. Dose reduction of antipsychotics was done for 51(17.0%) participants. Most of the participants' side effects were not managed according to American Psychiatric Association guideline; 178 (82.4%). The most common types of FGAs induced side effects were cardiovascular side effects 169(56.3%); sedation and CNS side effects 149(49.6%); and extrapyramidal side effects 114(38.0%). There is a significant association between occurrence of side effects of FGAs and duration of illness (P = 0.04). CONCLUSIONS: The prevalence of first generation antipsychotics induced side effects was high. However, management practice of the side effects was minimal.

Determinants of drug-related problems among ambulatory type 2 diabetes patients with hypertension comorbidity in Southwest Ethiopia: a prospective cross sectional study.

OBJECTIVE: The aim of this study was to assess drug-related problems and its determinants in type 2 diabetes patients with hypertension co-morbidity. RESULTS: A total of 300 type 2 diabetes patients with hypertension co-morbidity were studied. The majority of participants, 194 (64.7%), were males. Mean age of the participants was 54.44 ± 11.68 years. The mean durations of diabetes and hypertension were 5.37 ± 4.79 and 5.15 ± 4.65 years respectively. The most commonly prescribed antidiabetic medications were metformin in 200 (66.7%) and insulin 126 (42%) of the participants. Enalapril was the most commonly prescribed antihypertensive medication; 272 (90.7%). Aspirin was prescribed to 182 (60.7%) participants. Statins were prescribed to one-third (65.67%) of the participants. Eighty-five (28.3%) participants had diabetes related complications other than hypertension. A total of 494 drug related problems were identified. The mean number of drug related problems was 1.65 ± 1.05. The most common drug related problems were need for additional drug therapy (29.35%), ineffective drug (27.94%) and dose too low (15.8%). Independent predictors of drug related problems were age 41-60 years (AOR = 6.87, 95% CI 2.63-17.93), age > 60 years (AOR = 5.85, 95% CI 2.15-15.93) and the presence of comorbidity (AOR = 3.0, 95% CI 1.11-8.16).

Correction to: Antihypertensive medication adherence and associated factors among adult hypertensive patients at Jimma University Specialized Hospital, southwest Ethiopia.

After publication of our article [1] we became aware that we had not obtained permission to reproduce the questions from the eight-item Morisky's Medication Adherence Scale. The table in this Correction replaces Table 2 in our article. In addition, the second number for the MMAS-8 question 2 was incorrect and has been updated to 223(79.6).

Antihypertensive medication adherence and associated factors among adult hypertensive patients at Jimma University Specialized Hospital, southwest Ethiopia.

BACKGROUND: Adherence to antihypertensive medications is a key component to control blood pressure levels. Poor adherence to these medications leads to the development of hypertensive complications and increase risk of cardiovascular events which in turn reduces the ultimate clinical outcome. The purpose of this study was to assess antihypertensive medication adherence and associated factors among adult hypertensive patients. A hospital-based cross-sectional study among adult hypertensive patients was conducted at hypertensive follow-up clinic of Jimma University Specialized Hospital from March 4, 2015 to April 3, 2015. A simple random sampling technique was used to select the study participants from the study population. The study patients were interviewed and their medical charts were reviewed using a pretested structured questionnaire. Adherence was assessed using Morisky Medication Adherence Scale-8 (MMAS-8) and MMAS-8 score less than 6 was considered as non-adherent and MMAS-8 score was ≥ 6 was declared as adherence. Factors associated with adherence were identified using binary and multivariate logistic regression analysis. Crude odds ratio, adjusted odds ratio (AOR) and 95% confidence interval of the odds ratio were calculated using SPSS version 21. Variables with p-value less than 0.05 were assumed as statistically significant factors. RESULTS: Among 280 hypertensive patients, 61.8% of the study participants were found to be adherent. More than half (53.2%) of the participants were males and the mean age of the participants was 55.0 ± 12.7 years. Co-morbidity (AOR = 0.083, 95% CI = 0.033-0.207, p < 0.001), alcohol intake (AOR = 0.011, 95% CI = 0.002-0.079, p < 0.001), getting medications freely (AOR = 0.020, 95% CI = 0.003-0.117, p < 0.001), and combination of antihypertensive medications (AOR = 0.32, 95% CI = 0.144-0.712, p < 0.005) were inversely associated with antihypertensive medication adherence. CONCLUSION: The adherence level to the prescribed antihypertensive medications was found to be sub-optimal according to the MMAS-8, and influenced by co morbidity, alcohol intake, self-purchasing of the medications and combination of antihypertensive medications.

Glycemic control and associated factors among type 2 diabetic patients at Shanan Gibe Hospital, Southwest Ethiopia.

OBJECTIVE: The aim of this study was to assess the rate of glycemic control and factors affecting glycemic control in type 2 diabetic patients. RESULTS: A total of 174 type 2 diabetic patients were interviewed and were studied. Mean age of the patients was 48.98 ± 14.96 years (range 18-80 years). More than half (51.7%) of the patients were males. About a third of patients, 53 (30.5%), were on antidiabetic medications for less than 5 years. The most common prescribed antidiabetic medications were insulin, 48 (27.6%), and metformin 15 (8.6%). One hundred seven (61.5%) patients were on combination therapy (two drug treatment) and the remaining patients were on monotherapy. The majority, 103 (59.2%), of patients had uncontrolled blood glucose. A larger proportion of female patients, 54 (52.4%), had uncontrolled blood glucose than males. Level of education (p < 0.001) and duration of diabetes treatment (p < 0.001) were significantly associated with glycemic control. Adherence of patients to regular follow up (Adjusted Odds Ratio (AOR) = 2.42, 95% CI 1.08-5.44, p = 0.03) and diabetes treatment for 5-10 years (AOR = 4.64, 95% CI 1.79-12.06, p = 0.002) are found to be independent predictors of glycemic control among type 2 diabetes patients.

Assessment of Blood Pressure Control among Hypertensive Patients in Southwest Ethiopia.

BACKGROUND: The rate of blood pressure control among hypertensive patients is poor and the reasons for poor control of blood pressure remain poorly understood globally. OBJECTIVE: To assess the rate of blood pressure control among adult hypertensive patients at Jimma University Specialized Hospital. MATERIALS AND METHODS: We conducted a hospital based cross sectional study among adult hypertensive patients at Jimma University Specialized Hospital hypertension clinic from March 4, 2015 to April 3, 2015. Data on sociodemographic characteristics of the participants and adherence to antihypertensive medication(s) were collected from patients by face to face interview using a pretested structured questionnaire. Comorbidities, antihypertensive medication(s) and blood pressure measurements were collected retrospectively from medical records. Medication adherence was assessed using Morisky's Medication Adherence Scale-8 score. We did the statistical analysis using chi-square test and binary logistic regression with level of α set at 0.05. Statistical significance was considered for variables with p<0.05. RESULTS: Out of 311 participants, 286 patients were eligible and were studied. More than half, 154 (53.8%), of the participants were males. The mean age of the participants was 54.8± 12.6 years (range 26 to 94). The majority, 196 (68.53%), of the participants were taking more than one antihypertensive medication. More than one third (39.5%) of the participants were non adherent to their medication(s). The rate of blood pressure control was 50.3%. In a univariate logistic regression analyses, age ≥65 years old (P = 0.008), physical inactivity (p<0.001), chat chewing (P<0.001), adding salt to food (P<0.001), and coffee use (P<0.001) are significantly associated with uncontrolled blood pressure. CONCLUSION: Almost half of the hypertensive patients on follow up had uncontrolled blood pressure. We recommend better health education and care of patients to improve the rate of blood pressure control at the hospital.

Adherence to Treatment and Factors Affecting Adherence of Epileptic Patients at Yirgalem General Hospital, Southern Ethiopia: A Prospective Cross-Sectional Study.

BACKGROUND: Non adherence of epileptic patients to antiepileptic medication often leads to an increased risk of seizures and worsening of disease, death and increased health care costs. OBJECTIVE: to assess adherence to treatment and factors affecting adherence of epileptic patients at Yirgalem General Hospital, Southern Ethiopia. METHODS AND MATERIALS: We conducted a cross-sectional study on epileptic patients from February 9 to 22, 2015. Data were collected from patients ≥18 years old. Adherence was measured using the eight-item Morisky's medication adherence scale. All consecutive patients coming to epilepsy clinic during the study period were interviewed until the calculated sample size (210) was obtained. We collected patient demographics, perception about epilepsy and adherence to medication(s). We used chi-square tests and a binary logistic regression model for statistical analysis. Statistical significance was considered at P<0.05. RESULTS: out of a total of 210 participants, 194 were willing to participate and were studied. Of the 194 participants, 109 (56.2%) were males. The mean age of the participants was 33.62±11.44 years; range 18 to 66 years. The majority, 123(63.41%), of the participants were taking two antiepileptic medications. Sixty two (32%) of the participants were adherent to their treatment. The most common reported reasons for non-adherence were forgetfulness 49(75.4%) and run out of pills 7(10.8%). Factors that affect medication adherence are epilepsy treatment for <1 year (P = 0.011), epilepsy treatment for 1-3 years (P = 0.002), epilepsy treatment for 3-5 years (P = 0.007), being married (P = 0.006), grade 9-12 education (P = 0.028), college or university education (P = 0.002) and absence of co-morbidity (P = 0.008). CONCLUSIONS: The rate of adherence observed in this study was low. The most common reason for non- adherence was forgetfulness. Therefore, the hospital should devise strategies to improve adherence of epileptic patients at the hospital.

Predictors and treatment outcome of hyperglycemic emergencies at Jimma University Specialized Hospital, southwest Ethiopia.

BACKGROUND: Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) commonly known as hyperglycemic emergencies are the two most common life-threatening acute metabolic complications of diabetes. The objective of this study is to assess predictors and treatment outcome of hyperglycemic emergencies (HEs) among diabetic patients admitted to Jimma University Specialized Hospital (JUSH). METHODS: It is a three year retrospective review of medical records of patients admitted with HEs at JUSH. Patient demographics, admission clinical characteristics, precipitants, insulin used and treatment outcomes were extracted. Statistical analysis was done using student's t test, Chi square test, and binary logistic regression with level of α set at 0.05. Statistical significance was considered for variables with p < 0.05. RESULTS: Complete data was available for 163 out of 421 patients admitted with HEs. The majority (62.6 %) were males. Mean age of patients was 36.6 ± 15.9 years. About 64 % of patients had type 1 diabetes. About 93 % of the participants developed DKA. The most common precipitants of HEs were infections 95 (59 %), non-compliance to medications 52 (32.3 %), and newly diagnosed diabetes 38 (23.6 %). Recurrent hyperglycemia, hypoglycemia and ketonuria occurred in 88 (54 %), 34 (20.9 %) and 31 (20.5 %) patients respectively. Mean amount of insulin used and duration of treatment till resolution of DKA were 136.85 ± 152.41 units and 64.38 ± 76.34 h respectively. The median length of hospital stay was 6 days. Mortality from HEs was 16 (9.8 %). Admission serum creatinine >1.2 mg/dL (P = 0.018), co-morbidity (P < 0.001) and sepsis (P = 0.014) were independent predictors of HEs mortality. CONCLUSIONS: Infections, non-compliance and new onset diabetes were the most common precipitants of HEs. Length of hospital stay and mortality were high. High use of insulin, recurrent hyperglycemia, hypoglycemia, and ketonuria were common during HEs management. Elevated serum creatinine, sepsis and co-morbidity are independent predictors of HEs mortality.