Health professionals identified barriers, facilitators, attitudes, and benefits of T2D treatment in primary health centers, which were grouped into three main categories: healthcare system, HCPs, and patients (Figure 1).
BARRIERS ASSOCIATED WITH HEALTH SYSTEM MANAGEMENT
Excessive workload and lack of human resources
The disproportionate clinicians-to-patient ratio was mentioned by the participants as a major problem affecting proper individual medical consultations. They added that only a few doctors and nurses run the diabetes clinic and have to attend to long queues of patients beyond official working hours. Thus, often patients are given longer appointments for medical follow-up.
Too many patients with diabetes are attending consultations, which does not allow adequate centered care for each patient (D).
Diabetic patients and health workers suffer due to too much workload (N).
Lack of enough staff to listen well (N).
We give longer appointments (D).
Nurses have mentioned that one nurse is responsible for multiple tasks, which is time demanding.In addition, participants attribute shortage of staff to lack of recruitment and demotivated staff who are overdue for retirement but still in public service. Besides the lack of general practitioners in PHCCs, the doctors said there are no medical specialists to attend to patients with T2D requiring advanced care, and added that the nurses are not certified, diabetes specialists.
The nurses do not do their job due to lack of time, workload (N).
Staffs are already old, sick, and demotivated (3 years above retirement age) almost 41 years of civil service (N). Specialists are no longer available in diabetic centers (D).
If a patient is hypo or hyperglycemic, there is no referral to a specialist (N).
Restricted referral policy to diabetes centers
The referral system is vague and patients find it difficult to make the transition from PHCCs to specialized healthcare centers. Participants noted that the Centre de Référence Préfectoral Diabétologie et Maladies Chroniques restrict referral of T2D patients to limited figures as opposed to the large number of patients with complications who need specialized care. Nurses mentioned that doctors exercise power autonomy by monopolizing the decision for referring patients to specialized care. More so, nurses perceived that they always had to fill in too much patient information on the computer during consultations. They said it demands too much time and effort, as they have too many patients to attend to.
Centre de Référence Préfectoral Diabétologie et Maladies Chroniquesgives us a specific number of patients for referral (N).
Ambiguous referral system and difficult for the patient to identify (D).
It is only the doctors who recommend a referral if a patient is unstable or has complications (N).
Complex database for health record information system (N).
Poor reimbursement policies and working environment
At public hospitals, all HCP’s salaries are paid by the Ministry of finance. Doctors perceived their salary as low and not meeting their expectations. Participants described their working environment as having deteriorating working conditions. In addition, they mentioned that the universal medical coverage is inadequate due to lack of medical equipment and often the disrupted supply of free drugs. In addition, necessary medical investigations are left undone due to the poor economic status of the patients.
Lack of motivation in health professionals (D).
Lack of adequate premises and diabetes education materials (N).
The government cannot provide complete medical coverage for all the people. Lack of blood glucose meters. Routine assessment of lipid profile and HbA1c every three months are not done, because it's expensive. Lack of drugs. Patients do not buy drugs, because they are poor. Blood tests are not done and patients abandon their follow-ups (D).
BARRIERS ASSOCIATED WITH HEALTHCARE PROFESSIONALS
The Gap in doctor’s knowledge
General practitioners expressed their incapability to manage elderly patients and complications. Questions about the general knowledge of T2D revealed that doctors perceived T2D as a chronic disease frequently found in young adults and the elderly population, and further highlighted heredity, obesity, and sedentary lifestyle as associated risk factors. They mentioned that treatment is non-insulin-dependent and lifestyle-oriented.
Doctors only control the blood sugar and prescribe medication. When there are complications nothing can be done. They always come with complications (diabetic feet, amputation, or dialysis) (D).
We do not target stable glycemic control in the elderly because it is difficult (D).
Chronic disease, disease of the century. In all age categories above 30 years. Associated with heredity, obesity, or sedentary lifestyle. Clinically, a serious pathology. Requires assessment and multi-discipline monitoring (D).
BARRIERS ASSOCIATED WITH PATIENTS
The participants expressed that beliefs about T2D among Moroccan patients are constructed out of cultural values and spiritual beliefs. Several patients believed that any illness including T2D comes from Allah (God) and he decides their fate with or without having T2D. This belief made them less likely to follow lifestyle changes advice. However, they do pay attention to getting free medicines.
Patients do not accept their illness and do not adhere to diet advice, everything. Always the diabetic patients perceive higher HbA1c as caused by stress. They just need the drugs (D).
Participants mentioned that patients’ willingness to adhere to treatment advice is negatively influenced by their poor socioeconomic status. Doctors mentioned the role of gender in terms of adherence to advice in favor of men. Nurses added that patients of advanced age did not engage in physical activity. Nurses said T2D patients were often prescribed antidepressant drugs, it influences their behaviors.
Patients’ adherence to advice depends on socioeconomic status, culture, and education level (D).
Men adhere to advice more than women (D).
Aged have a problem especially with physical activity (N).
Diabetes patients always take psychotropic drugs (N).
FACILITATORS AND BENEFITS ASSOCIATED WITH HEALTH SYSTEM MANAGEMENT
Participants suggested that an institutionalized referral system to a specialist, a simplified electronic health record, a continuous supply of free drugs, a diagnostic tools referral system, and recruitment of more HCPs into the civil service will augment structured T2D care in primary centers.
Availability of drugs and equipment in adequate quantity and quality. Free routine medical investigations, for example, HbA1c and blood glucose. Recruit young competent staff. Simplify the health record database. Provide nurses just responsible for type 2 diabetes. Reduce appointment times (D).
You need a nutritionist, dietetics, or nurse at CRD (in case of obesity) …. Ensure endocrinology consultation 1 time in 3 months in the primary medical centers (N). They added that there is a need to improve the working atmosphere. Favorable working conditions, air conditioning (N).
FACILITATORS AND BENEFITS ASSOCIATED TO HCPs AND PATIENTS
Participants recognized the need to engage in lifelong learning. They mentioned attending training would benefit continuously upgrading their skills. On the other hand, the participants perceived the provision of free medical services as an approach that will promote diabetes self-management and therapy adherence. In addition, they stressed the need to use social media to create awareness and to promote diabetes education.
Continuous professional development program for staff that will provide diabetes education (D).
Free medical consultation for these patients. Otherwise, patients will neglect the disease if not provided with their needs, everything (D).
Therapeutic education should be done in the media and social networks for detailed diabetes education (D).
Locally adapted poster and teaching material (N).