Three major themes emerged: 1) Health system preparedness to manage diabetes comorbidities, 2) Challenges faced by physician to treat diabetes comorbidities, and 3) Patients' related factors in management of diabetes comorbidities. [Table 1] The findings are presented under each theme and category with quotes from the participants.
Theme 1: Health system preparedness to manage diabetes comorbidities
The health system played a crucial role in the management of patients. While lack of regular supply of medicines, poor laboratory services in the health facility, lack of trained human resources were some of the common barriers for all physicians, few facilitators like NCD awareness campaigns and periodic follow up of the patients by the community level health workers helped in improving the quality of management.
Category 1: Challenges in relation to infrastructure and logistics
Medicines: The dependence of UPHCs on the government’s central medicine store for their medicines frequently leads to irregular supply of medicines to the UPHCs for NCDs like diabetes mellitus and hypertension. Moreover, the unavailability of medicines for different chronic conditions was also considered to be an important barrier by all physicians.
P4- “To the only diabetic patient we give the medicines to decrease the blood sugar level but in comorbidity we also have to treat the other diseases and sometimes we don’t have the supply of diabetes medicines... in other chronic diseases we have for acid peptic disease… blood pressure also the medicines come but periodically”.
Laboratory facilities: All physicians felt that the absence of good laboratory facilities hampered their management of diabetics with comorbidities. The dependence on reports from private laboratories which were either unreliable or proved to be a cost burden for the patients forced them to refer the patients to higher level of public health care facilities.
P4- “Patients want all tests to be done at one place but due to unavailability of these facility they have to face many problems.”
Inadequate human resources and lack of trained support staff: Most of the facilities were affected with lack of skilled staff and in many cases the allied health personnel were handling more than one responsibilities. This hampered delivering multidisciplinary services necessary for diabetes patients with comorbidity.
P10- “without proper staff it’s difficult to manage a UPHC... Now we are 3 staffs here… I doctor, one pharmacist and one sweeper…. we don’t have any attendant or ANM or staff nurse. If both of them are missing in a same day I face a lot of problems managing alone”.
Category 2: Management of records and documentation
Poor record keeping or no registration of chronic disease patients: The absence of any formal record or shared record of chronic disease patients made the task of management and multidisciplinary collaboration difficult.
P9- “They come with the reports after tests and with no record we don’t know their condition in the past and they do many tests again and again. Repetition mostly happens because we don’t keep any records”.
Lack of formal referral and back referral channels: On referral procedures, participants shared that they there is no formal record system of referral and back referral and most of the time they do not know the outcome of their referral to higher centres. They felt that a back referral record or feedback would make them more connected and involved with the treatment of the conditions of the patient.
P1- “I send the complicated cases to the Capital hospital… sometimes they come back with reports... sometimes they don’t come”.
Pharmaceutical companies: The support by pharmaceutical companies and medicine representatives in provision of journals and updates on the new treatment and drug composition was perceived as an enabler by some participants. They felt it helped them in staying abreast of the latest treatment modalities in chronic conditions.
P16- “Pharma companies also give us a lot of journals for diabetes and other chronic diseases… and medicine representatives inform about new medicines and their composition”.
Category 3: Community participation and literacy
Awareness campaigns: The awareness campaigns that included information, education and communication (IEC) on NCDs in the community and health facilities was perceived as a facilitator to management. It was felt these activities encouraged patients to seek advice for their conditions and made them more attentive to their treatment.
Community level health workers: The role of community level health workers like Multi-Purpose Health Workers (MPHW): The role of MPHW in creating awareness among population and following up with the patients personally on their treatment and health conditions helped the physicians to be more responsive in assessing the patients in the health facility catchment area. They also brought the more serious patients with multiple conditions to their notice for intensified care.
Themes 2: Challenges faced by physician to treat diabetes comorbidities
Category 1: Barriers to provide effective treatment
Barriers in relation to knowledge and skills: The lack of formal training on diabetes and comorbidities management was perceived as a major constraint for quality management of diabetes patients with comorbidities. Physicians expressed that managing such patients especially those on insulin treatment was beyond their knowledge domain and they did not have the necessary clinical skills to manage, hence they referred them to a specialist. Most relied on internet, journals, books and sometimes representatives from pharmaceutical companies to update themselves. Those physicians who had not received any training were not aware of standard clinical guidelines for treatment of chronic conditions.
P10- “they give training only on the current epidemic… yes of course, if there would have been some training on NCD…then there we could have a standardised procedure for treatment, we could have followed a protocol of state govt. By which we could sort out the problems we are facing daily”.
Barrier in relation to communication skill: Physicians felt they were unable to put forth the necessary advice to the patients with diabetes and comorbidities in an effective way and agreed that communication skills could help in overcoming this barrier. They opined the specialist or endocrinologist can help the patient to understand his comorbid condition better and therefore they referred the patient to a specialist.
Patient load: The average time spent by the physicians for a consultation with a diabetes patient ranged from three to ten minutes. They expressed that within limited working hours and overburden of patients it is difficult to reserve adequate consultation time and it affected the quality of care. Most UPHCs in the study were managed by one doctor, and daily patient attendance ranged from 50 to 150.
P10- – “that depends if rush of patients is there then I don’t give much time. If few patients are there I give them minimum 5 minutes.... Some patient come with 3-4 last test reports in the rush time... I get irritated …still I treat them”.
Category 2: Facilitators for effective treatment
Facilitators for knowledge and skills: A limited number of participants had a formal one-year training in diabetes mellitus expressed confidence in handling the diabetes patients with comorbidities. Similarly, physicians who had attended any seminar or workshop on non-communicable diseases (NCDs) were more optimistic on handling of these cases. They were aware of the standard clinical guidelines for chronic conditions management and treatment protocols.
P3- “I have done a one-year diploma course in diabetes management…so I have no problem as such in clinical treatment”.
Facilitators for communication skills: The physicians who were confident in communication with the diabetes patients on their disease conditions found their patients to be compliant to the advices and more involved in the treatment plan. It was observed that those physicians who had received diabetes management training did not have any difficulty in communicating with the patients.
Time management skill: Physicians trained in diabetes management had allocated a separate day in a week for diabetes patients and expressed satisfaction about the time (about 20 minutes) devoted for consultation of these patients.
P6- “If a diabetes patient comes in a rush time who needs more time from me, I advise the patient to come on our weekly diabetes day... they have other problems also like heart problem, neuro, kidney related problem, I can spend more time with them by explaining them about how to change their lifestyle. I also advise on exercise, diet. It crosses 20- 30 minutes sometimes”.
Networking with seniors, specialists: Physicians who discussed and sought advice from senior colleagues and specialists in higher centres felt more confident in handling the diabetic patients. Few physicians who went once a week to a centre with specialists for duty, observed the specialists, senior colleagues’ management practices (peer learning) and felt more confident in handling the patients in their own facility.
In the management of diabetics with comorbidities there were factors relating to physicians, which were barriers and facilitators to quality care. Those physicians who had had any training in diabetes kept a separate day for managing diabetes patients and did not perceive the care for diabetes patients with comorbidities as added burden, while others who were not trained felt overburdened when treating them in their daily practice. It was observed that training correlated to increased confidence and time management and the trained physicians appreciated the additional needs of patients with diabetes and comorbidities. The trained physicians did not express any difficulty in communicating with diabetes patients about comorbidities but others found it hard to communicate.
Empathy: Counselling and maintaining an empathetic relationship with the patients was found to be a facilitator. All physicians agreed on the importance of patient education and counselling. Physicians who had an empathetic relationship with the patients and counselled them felt they had cooperative and satisfied patients. They also felt they were able to manage the multiple demands of patients with diabetes and comorbidities.
P3- “I treat them as my family member. I try to make them understand everything clearly ... So might be for this they follow my advice and are regularly coming to me”.
Theme 3: Patients' related factors in management of diabetes comorbidities
Majority of the patients seeking care from the primary urban health center belong to slums or belong to low socioeconomic group, according to the physicians – most of them have poor financial conditions, low or moderate literacy and migrants. Physicians felt that patient’s cooperation, financial condition and awareness played a significant part in the management of diabetes. While a non-compliant patient or apprehensive patient’s adherence to treatment was poor, a cooperative patient made management easy. Similarly, the economic background dictated many of the treatment choices during management.
Category 1: Treatment adherence
Physicians felt diabetes patients’ adherence to the treatment to be an important factor in quality management. Patients who adhered to treatment had better clinical outcomes and less referrals than the non-adherent patients with diabetes. They expressed multiple issues affecting the adherence.
Attitude and belief: Physicians reported occasionally that patients discontinued their treatment with the assumption that they were cured. Later deterioration of the conditions led to more challenges in management for the physician. Mistrust of patients on quality of care supplied at the health care facilities also influenced the adherence to prescribed treatment.
P7- “some have the affordability but they are not serious……they get irritated for having to take medicine regularly”
P15- “Some people are health conscious…they ask questions…. what to eat…complications of diabetes…they also do regular follow up”.
Appraisal of comorbidity: Physicians felt some patients perceived their multiple chronic conditions and treatment as non-serious and did not warrant regular treatment, which decreased their adherence to treatment and follow up.
P2- “Some people hesitate to take those drugs……. those few which is in supply. They have wrong notion towards government supplied medicines that they are not good”.
Category 2: Healthcare expenditure
Low economic status of the patients was found to be a barrier to management as low affordability of patients affected the choice of drug therapy, giving priority to the most urgent condition only. Physicians felt frustrated when patients with poor financial power who need specialist care were hesitant to go to specialized centres upon referral and insisted on being treated at the primary care level.
P16- “depending upon his financial condition and how much he can spend regarding medicines, as per that I prescribe medicine for the most necessary condition”
P9- “Most of the diabetes cases with many conditions we refer but some people do not prefer to go because of losing money”.
Category 3: Maintaining a personal treatment record
Patients with diabetes who maintained a record of their past treatment were found to be more cooperative and aware about their health conditions by the physicians compared to those without a medical record. They perceived this to be helpful in avoiding duplication of tests and keeping a track on the treatment plan of comorbidities. Those patients with records were also more observant to deterioration of their conditions and sought prompt treatment.