Barriers to Accessing Quality Health Care for Diabetes Patients at the Suva Diabetes Center: A General Descriptive Mixed Method Study

Introduction:
Despite the development of evidence-based clinical practice guidelines for glycaemia, cholesterol and weight control in Fiji, more than half of diabetic patients are still not reaching their recommended control goals. This could be due to multiple factors that are associated with barriers to patient diabetes control. The primary purpose of this study was to explore the perceptions, and identify barriers, to accessing quality health care at the Suva Diabetes Centre (SDC) among patients, their caregivers and health care workers.
Methods:
The conceptual framework of this study was a modified Levesque model of access that examined three abilities: the diabetic patients’ ability to access, the care-givers’ ability to support patient access, and the health care workers’ ability to provide quality health care. It also examined five dimensions of access to health care: the availability of health services to patients, the flexibility of the services delivered in the center, the acceptability of diabetes patients’ care and health condition, the appropriateness of services provided in the facility, and the affordability of accessing quality diabetes care.
A mixed-method study was conducted among 45 registered diabetes patients between July 2019 to September 2019, at the Suva Diabetes Centre (SDC), using convenience sampling with the following inclusion criteria: patients who were referred to the SDC between the 1st September 2018 to 30th November 2018, had current folders at SDC, were attending clinics during the data collection phase from 1st July to 31st August 2019, were residing locally, mentally fit, and voluntarily agreed to participate. Those that did not meet the inclusion criteria and had been transferred back to their health facilities were excluded from the study. A patients’
experience survey was used to identify barriers experienced by diabetic patients. Pearson's’ correlation using SPSS v-25 was used to identify relationships between independent variables and patient responses to the patients' experience survey. A p-value of <0.05 was considered statistically significant. The qualitative component included 11 caregivers of diabetic patients referred to SDC and 7 health care workers from the same facility who were mentally fit to participate voluntarily through in-depth interview sessions. Those who declined participation were excluded. Theory-based deduction (Grol and Wensing method) using Microsoft excel was used to analyses qualitative data. The study obtained ethical approval from ethics committees of the Fiji National University, College of Medicine, Nursing and Health Sciences and the Ministry of Health and Medical Services.
Results:
Of the 45 patients who agreed to participate, 22 were females (48%), the mean age was 48.04 years (range10 -80 years) and 71% were <60 years of age. Fijians of Indian descent composed 55.5% of the sample. 91.1% were non-smokers and non-alcohol users, 73% adhered to physical activity advice and 77.8% adhered to dietary advice. However, the mean body mass index (BMI) was 29.4 kg/m2 where 82.24% were either overweight or obese, 97.87% had poor glycaemic control (HbA1c) with the mean of 10.4% and 62.2% had high cholesterol levels with a mean of 5.52mmol/l. This mismatch between high level of adherence to health advice and poor test results was due to multiple barriers patients identified including “unfriendly infrastructure” and space (100%), lack of social support (44%), limited access due to work engagement (26.8%), cost of transportation and residing far from the clinic (48%), lack of financial support to buy health services (drugs and tests) (68%), inability to eat recommended diets (68%), fear of attending the clinic (12%) and staff attitudes (22%). Positive correlations were identified between ethnicity and the patients’ confidence in health care workers (ρ = 0.33, p-value =0.02), overall experience with health
care worker (ρ = 0.34, p-value =0.04). Females and experience in accessing clinic (ρ = 0.38, p-value =0.01) and education level with patient adherence to physical activity advice (ρ = -0.32, p-value =0.03). Enabling factors included: efficient (86.60%) and organized work environment (68%) at SDC, quality of care (100%) and emotional support (88.80%) from HCWs and recognition of family support (100%).
Of the eleven caregivers participating in this study, 72.80% were >40years old (mean of 46), 90% were female and 54.5% were Fijians of Indian Descent. Five major themes emerged as key determinants of the quality of care from the in-depth interviews,: affordability of health service (limited financial support, competing commitments of care-givers), availability of health services (unavailability of essential services), accommodative features of the facility (physical access and condition of health facility), acceptability of condition and care (limited knowledge of relative’s condition, lack of awareness of control measures, non-adherence to care, lack of family and social support and emotional aspects of the caregiver) and appropriateness of service provided (caregivers trust to health care service providers and caregiver satisfaction with the services provided).
Of the seven health care workers participating in this study, 71.5% were >40 years old (mean of 41.89), 85.7% were females and 57.2% were I-Taukei. Four major themes were identified, three on barriers to the provision of health care and one on the enabling factors. These included: barriers towards patient-related factors (knowledge gap among patients, non - adherence to treatment and poor patients support from caregivers barriers towards health-care workers practice (improving health care workers knowledge and skills), barriers to the facility operations (lack of human resource, unclear protocols on service delivery and operational processes, stock-outs and unavailability of medicine, consumables and medical equipment, poor condition of health facility) and enabling factors (influence to policy chance I don’t understand this, patient-centered holistic approach)
Conclusion
This study identified barriers to quality diabetes care among patients, caregivers and health care workers. Barriers identified by patients included health care financing, social support mechanisms, health education and literacy, patients’ identity, language, belief system and, attitude of health care workers. Similarly, the caregivers highlighted the importance of maintaining essential support systems to ensure quality diabetes care for patients. The health care workers highlighted the importance of recognizing existing social structures that patients can use to access quality health care and thereby ensure a supportive environment for patients, and conducive space for caregivers and health workers to work in. The burden of diabetes and its complications cannot be reduced if the health system fails to recognise the barriers of access to quality diabetes care.
Recommendation
The SDC and MOHMS should consider more inclusive outreach programs such as peer-supported education and diabetes shift-clinics that include access to diabetes specialty services to the patients and their care-givers. MOHMS health facilities should ensure supportive environment that enhance access and support for patients and their care-givers and, a friendly working environment for health care workers to work in. These include refurbishments to meet the services and access needed by patients and more conducive space that could enhance continuous health education for patients, their caregivers and the health care workers.