Perspectives of healthcare providers and patients with type 2 diabetes mellitus on improving glycaemic control in Kinshasa, Democratic Republic of the Congo: a qualitative study

doi:10.21203/rs.3.rs-2957475/v1

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Perspectives of healthcare providers and patients with type 2 diabetes mellitus on improving glycaemic control in Kinshasa, Democratic Republic of the Congo: a qualitative study

https://doi.org/10.21203/rs.3.rs-2957475/v1

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Background

Despite advances in the therapeutic management of type 2 diabetes, glycaemic control remains suboptimal in sub-Saharan Africa, including in the Democratic Republic of the Congo (DRC). Defining interventions to improve glycaemic control requires a clear knowledge of local factors related to poor glycaemic control including the views and perspectives of key stakeholders such as healthcare providers and patients. Qualitative studies exploring these are lacking in the DRC. The aim of this study was to explore the perspectives of patients with type 2 diabetes and healthcare providers on ways to improve glycaemic control in the DRC.

Methods

This qualitative study utilized in-depth interviews conducted on 26 purposefully sampled participants − 10 patients with type 2 diabetes and 16 healthcare providers in Kinshasa, Democratic Republic of the Congo. The study used phenomenology approach, and inductive, constructionist, and thematic analysis. Themes were organized and integrated using the Innovative Care for Chronic Diseases Framework.

Results

Three themes were identified regarding improving glycaemic control: strengthening the healthcare system, supporting patients and population, and adopting supportive health policies. The improvement of glycaemic control involves actions from the patients and families, the healthcare organisations and the community, and policy environment. The patients should be empowered for self-management through a patient-provider relationship that is patient-centred. The care offered to patients with diabetes should be evidence-based and provided by multidisciplinary healthcare teams in well-equipped healthcare facilities. At the community level, efforts should focus on improving people’s knowledge of diabetes and provide more support to patients. At the policy level, primary prevention of diabetes and effective healthcare financing should be assured.

Conclusion

This study found that the improvement of glycaemic control for patients with type 2 diabetes in Kinshasa, DRC requires multidimensional strategies that include patient, family and community level interventions; structural and processes of care interventions in the health system; and health policy level interventions. To be efficient, these interventions need to be integrated into existing platforms of healthcare services delivery, particularly the chronic diseases management framework.

perspectives

glycaemic control

type 2 diabetes

qualitative study

Diabetes mellitus, like other non-communicable diseases, is gaining epidemiological and clinical importance worldwide. The increase in prevalence and the accompanying clinical consequences are expected to be felt mostly by low- and middle-income countries, where up to 94% of the total number of people living with diabetes are expected to reside by 2045 [1]. The impact of diabetes is considerable not only in terms of morbidity and mortality, but also in terms of economic impact [1–3].

Type 2 diabetes is the most common form of diabetes, and its prevalence is expected to rise because of ageing, economic development, and increasing urbanisation leading to more sedentarily lifestyles and greater consumption of unhealthy foods linked with obesity [1]. Africa as a region is experiencing the greatest increases in the number of cases of diabetes worldwide and also has the highest prevalence of undiagnosed diabetes [4, 5]. In the Democratic Republic of Congo, the prevalence of diabetes will also increase, with urban areas most affected [1].

One of the goals in diabetes management is the control of blood sugar, which avoids or reduces the risk of diabetic complications. When complications occur, these impose additional costs to patients and reduce patients' quality of life [6, 7].

Many advances have been made on the therapeutic level including the development of evidence-based guidelines and the addition of new anti-diabetic medications. However, the results in terms of glycaemic control are not obvious. On the global level, only half of patients with diabetes are controlled [8]. In sub-Saharan Africa, blood sugar control rates are very low [9]. And, in the Democratic Republic of Congo, recent studies in type 2 patients show rates ranging from 14 to 30% [10].

Studies into interventions for blood glucose control in diabetics require a clear knowledge of factors related to poor glycaemic control. These factors are multiple and vary depending on the context [11–13]. Very few studies have dealt with the lived experiences of patients on glycaemic control [14], and those assessing the perspectives and experiences of key players, patients and healthcare providers, on improving glycaemic control are very scarce. This is the case at present in the Democratic Republic of Congo. Nevertheless, patients and healthcare providers’ perspectives have been found essential to build an adequate and responsive healthcare system for diabetes care [15]. These perspectives are numerous and vary according to settings and may be different from patients to healthcare providers [16].

A systematic review found that nine themes were identified for better diabetes management by providers and patients: community linkage, health service system for diabetic patients, continuity of care, self-management, providers' support, referral system, patient-provider interaction, increasing competency of healthcare providers and family support; these nine themes showed various gaps interfering with the diabetes management in the two directions [17]. A study in Muscat, Oman, on patient-provider interaction from the perspectives of type 2 diabetes highlighted that development of communication skills that is patient-centred, efficient use of resources available in diabetes clinics and a close collaboration of families and patients with the healthcare team are necessary to improve diabetes care [18].

In rural South Africa, in a study on diabetic patients’ perspectives on challenges for glycaemic control, participants recommended lifestyle adjustments, improving compliance, retention of doctors at clinics, and social support as essential elements for improving glycaemic control [19]. However, lifestyle adjustments have been found to be difficult to attain among patients with type 2 diabetes. In a study in Brazil, conceptions about the disease and its control, use and access to healthcare, professional-patient relationship, social support and environment, and personal experience with the disease, acted as facilitator or barriers to the change [20]. In another study, both patients and providers identified psychosocial, socioeconomic, physical, environmental, and cultural factors as major barriers to self-care for patients with type 2 diabetes [15].

In the DRC, to the best of our knowledge, there have been no studies that had explored patients’ and health providers’ perspectives on the control of type 2 diabetes. This gap in literature has clinical, health research and policy implications and suggests missed opportunities of gaining a robust understanding of diabetes care and glycaemic control in DRC and limits effective interventions to improve the status quo. Therefore, the aim of this study was to explore the perspectives of patients and healthcare providers on ways to improve glycaemic control in the DRC.

Study design

This was a qualitative study that explored the perspectives of patients with type 2 diabetes mellitus and health providers regarding the ways to improve glycaemic control in Kinshasa, DRC. This study was part of a project on developing a framework for improving glycaemic control among patients with type 2 diabetes in Kinshasa, DRC [21]. The preceding phases of the project included: factors driving glycaemic control in sub-Saharan Africa: a systematic review and meta-analysis and, a mixed-method cross-sectional study on factors associated with poor glycaemic control in Kinshasa, DRC. The current study is reported according to the consolidated criteria for reporting qualitative research (COREQ) [22].

Theoretical framework

This study is based on a phenomenology approach which is premised on participants sharing their perspectives on a topic or issue - glycaemic control in Kinshasa, DRC [23]. Literature has shown that perspectives from patients and providers about improving glycaemic control were multiple [16] and that the inter-relatedness of these perspectives is best explored using the Innovative care for chronic conditions framework from the WHO [24]. The themes identified from this study resulted from inductive, constructionist, and thematic analysis processes of data collection and analysis [25].

Study setting

Kinshasa is the capital of the Democratic Republic of the Congo. It has about 16,315,534 inhabitants in 2023 [26]. The Democratic Republic of Congo is a low-income country located in Central Africa. A large majority of the population lives below the poverty line and experienced food insecurity [27]. The resources are very scarce and only a proportion of 4% of the budget is devoted to health [28]. Patients contribute to more than 70% of health expenditures as universal health coverage is not fully implemented, leaving most people uninsured.

The management of diabetes in Kinshasa is largely ensured by a structure called Kinshasa Primary Healthcare Network that combines health structures of the Catholic Church and the Salvation Army. A few other state and private clinics are caring for patients with diabetes. The diabetic clinics in these structures are managed by nurses and once monthly, a doctor comes to visit patients with diabetes. In Kinshasa, the pharmaceutical sector is largely dominated by private entrepreneurs who import the drugs; the distribution is also ensured by private merchants. The drug delivery is not reliable and the storage of products like insulin is of poor standard.

Study population and sample

For this study, we recruited health providers and patients with type 2 diabetes in Kinshasa Primary Healthcare Network, in the state and private healthcare facilities. Patients and healthcare providers aged ≥ 18 years were invited to participate. Patients were purposively selected ensuring that both controlled and uncontrolled patients, diversity of sociodemographic characteristics, and the duration of the disease are taken into account. Patients selected were those who have been followed for at least six months for diabetes and caution was taken to select those who were willing to discuss their views on improving blood glucose control. With regard to caregivers, preference was given to selecting providers with long experience of diabetes. Male and female providers were selected as well as doctors and nurses. The participants were excluded if they had difficulty communicating due to mental disability or refused to give consent.

For each category of participants, patients or healthcare providers, we stopped recruitment when the data saturation was reached [29]. Health managers in charge of the health structures helped in selecting the health providers to include in the study. In turn, health facilities’ teams who knew the patients helped in selecting them; these patients were then invited to come to the healthcare facilities for interviews. The selection of the participants took place from 21 October 2022 to 31 March 2023.

Data collection

The data collection was carried through in-depth interviews. The interviews were guided by an interview schedule (Additional file 1). The exploratory question was: "How do you think the control of glycaemia could be improved?" After that questions for clarification on what they said were asked to the participants. At the respective facilities, the principal investigator interviewed the participants in a quiet room where the confidentiality of the participants' statements was guaranteed. All interviews were audio recorded and lasted about 40–50 minutes. Each interview was analysed, and codes identified. Then in subsequent interviews, any new aspects, dimensions, or nuances of that code were identified, until no novelty emerged [29]. Data collection was held in strict observance of the COVID-19 infection prevention regulations in DRC.

Data management and analysis

The recorded interviews were transcribed verbatim and then translated into English by a language expert based at Kinshasa. The principal researcher who is fluent in French and Lingala verified the translation and transcription by re-listening to the audio recordings while reading the transcripts. The coding was performed independently by the principal researcher (JPF) and one supervisor (OBO) in selected interviews without any pre-conceptualized theoretical framework. The analysis was performed using the MAXQDA 2022 [30]. The analysis went through the six steps described by Braun and Clarke [25] - familiarization with the data, generating initial codes, searching for themes, reviewing potential themes, defining and naming the themes, and producing the report. Outlying perspectives were sought out, and an explanatory model that best explains the inter-relatedness of themes was developed.

Credibility, transferability, dependability, and confirmability

The credibility of the study was enhanced through triangulation of findings. Two experts in diabetology assisted in reviewing and conceptualizing the findings of the study. The findings were submitted to four participants to seek their agreement with identified themes. The thick description of data ensured transferability; external audits conducted by the supervisors ensured dependability, and confirmability was ensured by external audits and audit trail [31].

A total of 26 participants were included in the study − 10 patients with type 2 diabetes and 16 healthcare providers. None of the participants invited for inclusion in the study refused or was excluded. The Table 1 summarizes the participants’ characteristics.

Table 1

Sociodemographic characteristics of the participants in Kinshasa, n = 26 (2023)
	N (%)
Patients
Age (years)
< 40	1 (3.8)
40–65	7 (26.9)
≥ 65	2 (7.7)
Sex
Male	4 (15.4)
Female	6 (23.1)
Occupation
Employed	5 (19.2)
Unemployed	5 (19.2)
Duration of diabetes(years)
< 5	1 (3.8)
5–10	3 (11.5)
≥ 10	6 (23.1)
Health providers
Age (years)
< 40	5 (19.2)
40–65	6 (23.1)
≥ 65	2 (7.7)
Sex
Male	9 (34.6)
Female	7 (26.9)
Category
Doctors
Specialists	6 (23.1)
Generalists	5 (19.2)
Nurses	4 (15.4)
Nutritionist	1 (3.8)
Number of years of experience on diabetes (years)
< 5	1 (3.8)
5–10	7 (26.9)
≥ 10	8 (30.8)

Table 1 Sociodemographic characteristics of the participants in Kinshasa, n = 26 (2023)

Three major themes were identified for improving blood glucose control for type 2 diabetes patients in Kinshasa (Table 2).

Table 2

Themes identified for improving glycaemic control, Kinshasa, Democratic Republic of the Congo, 2022–2023
Theme	Sub-themes
Strengthening the healthcare system for diabetes care	Defining a management protocol
	Training of healthcare providers
	Providing basic materials
	Organising a reliable drug delivery system
	Promoting self-management
Supporting patients and population	Community sensitization about diabetes
	Involving families as support system to patients
Adopting supportive policies	Fight against poverty to address socioeconomic disparities
	Effective financing of the healthcare system
	Support activities for prevention of diabetes
	Multidisciplinary approach

Table 2 Themes identified for improving glycaemic control, Kinshasa, Democratic Republic of the Congo, 2022–2023

Theme 1: Strengthening the healthcare system

This first theme summarises the necessary actions to be taken in the health system and comprises of four sub-themes: defining a management protocol, training of healthcare providers, providing basic materials, organising a reliable drug delivery system, promoting self-management, and individualized care.

Defining a management protocol

The evolution of disease management requires knowledge updates, which are essential for patient support. The participants recommended that there should be an updated management protocol and continuing professional development for healthcare providers engaged in diabetes care. At present, the different healthcare facilities manage patients with diabetes according to their own rules. Isolated healthcare providers are not guided by any official guideline:

"Many of our staff care for diabetes based on training they followed (received) since 5 to 6 years ago. There is a need to re-train so that they can improve the way they are taking care of diabetes." (Generalist, Male, 5 years of experience)

"There is no normative document to guide the management of diabetes. It would be desirable to have them to guide the management and that even if a doctor is isolated, he can be guided in the way to treat the diabetic patient" (Nurse, Male, 11 years of experience)

The lack of a management protocol reflects the inefficiency of the national diabetes control program. This is the program that is dedicated to bring together all stakeholders in the fight against diabetes: universities, caregivers, donors, government. The participants also recommended close collaboration between the universities with the other actors by reinvigorating the Congolese National Diabetes Society.

Training of healthcare providers

When patients present themselves to the health centre, the healthcare provider needs to have been trained to manage the patient effectively. Participants reported that early diagnosis is of benefit for the patient and their glycaemic control:

"It (the health facility) must have a well-trained provider to carry out the diagnostic process and even offer opportunistic screening aimed at at-risk groups (Diabetologist, Male, 12 years of experience)

Only a small proportion of the personnel had training on how to manage diabetes. The participants recommended that the health providers in contact with the population in the primary healthcare facilities must receive training on diabetes care. Moreover, as the number of specialists on diabetes is limited and insufficient for the demand of care, participants recommended task shifting to help covering the demand of care.

"At our health center, the doctor comes once monthly, in the meantime, I’m taking care of patients with diabetes. I have been trained for this task. I can prescribe anti-diabetics, educate, and follow the treatment." (Nurse, Male, 42 years of experience)

Diabetes mellitus is a disease with somewhat a pervasive meaning in the population. A participant expressed that in many instances, patient’s denial is a common reaction to the evocation of the diagnosis of diabetes. This understanding of diabetes may constitute a barrier for appropriate care. Participants suggested an approach of progressively engaging with the patients to promote an understanding of diabetes and its management:

"In most cases, the first time you tell the patient about the diagnosis of diabetes, they will reject it; He (the patient) will seek to provide you with another explanation for his complaints. He will tell you that he has taken too much sugar lately or that he is under stress or that he has eaten beans. If you insist on convincing him that it's really diabetes, he's going to be gone forever. It must be done differently, with tact.

(Diabetologist, Male, 12 years of experience)

Providing healthcare facilities with basic materials

The participants expressed that many health facilities lack necessary equipment to confirm the diagnosis and monitor of diabetes. Some health centers in rural areas only have urine strip for glucosuria. Once the diagnosis is made and the patient might be followed, many health centers only base their follow-up on fasting blood sugar. They could not offer the battery of exams necessary for follow-up. The glycosylated haemoglobin is not available neither the tests for screening about the complications. The participants recommend that the health centers be equipped with necessary point of care tests/ materials for the diagnosis and follow-up of the patients. A participant suggested that equipping facilities should take account of the level of care and clinical responsibility:

"At the health center level, there is no need to do a lot of tests, blood glucose levels can be enough. When we multiply the examinations at the health center, it creates an additional cost for patients. In the follow-up of patients, those who are not controlled are referred to the secondary level and those with complications or comorbidities should be managed at the tertiary level." (Diabetologist, Male, 14 years of experience)

Organising a reliable drug delivery system

Type 2 Diabetes is a chronic condition requiring the adoption of life-long medications. If non-therapeutic measures are in the foreground, drugs would need to be added at some point and must be taken for a long time, if not for life. For patients who are mostly uninsured or have low incomes, affording medications is a real ordeal. Drugs are expensive and not easily available because there is no reliable drug distribution system. The lack of an organized drug delivery system also poses the problem of the quality of the drugs available in the setting. Apart from insulin, glibenclamide and metformin, the other more recently developed diabetic agents are not available in many primary care settings. In addition, patients lack facilities to store medications effectively e.g., fridge for insulin. The participants recommended the organisation of a reliable drug delivery system, even with the partnership of the private sector may help make medicines of acceptable quality available and affordable:

"What I can recommend is that drug products be available in our community." (Nurse, Male, 14 years of experience)

"The system must ensure that the medicines, mainly insulin, are stored according to the requirements. What we are seeing is that insulin is kept out of the fridge in many pharmacies". (Nurse, Female, 25 years of experience)

Promoting self-management

Type 2 diabetes is a lifestyle disease and succeeding in the care requires that patients engage in lifestyle modifications. Moreover, they must adhere to drug treatment and acquire technical skills required for successful implementation of drug treatment and lifestyle modification. The participants expressed that patients experience many barriers in their life with diabetes and recommend that patients be empowered for self-management:

"In the training, it is said that diabetics cannot make the parade in the hospital because he must know how to take care of himself. We do everything to teach them how to take care of themselves, so that they are able to check their blood sugar with their device and follow their treatment properly." (Nurse, Female, 9 years with diabetes)

As the patients are experiencing different challenges, the participants recommended that the education for self-management be individualized. Considering patients’ socio-economic levels, there are two categories of patients, firstly, patients who are poor and could not consistently afford the cost of care (purchase of medicines, carrying out follow-up examinations, recommended diet and lifestyle changes). Secondly, those who work and are covered by insurance but have difficulties adhering with lifestyle modifications: hygiene-dietary measures, lack of time for physical exercise and eating very late. Participants reported there is no suitable canteen or gymnasium at the workplace. Others, particularly the young are reluctant to adopt the requirements of the treatments, while the older people are limited by comorbid conditions:

"The diet must be individualized according to the economic resources of the patient with diabetes to render him able to afford what is prescribed (Family physician, Male, 4 years of experience)

"We have people who are bureaucrats, who work, sitting in offices. I tell them when you work in the office, do not sit there for more than one or two hours of time, you have to create activities that can help you make movements. Either you can go up and down the stairs for people who are working in offices on the second or third floor." (Generalist, Male, 15 years of experience)

To adequately identify the health needs and the context in which diabetes is experienced, participants recommended that healthcare providers develop good communication with the patients:

"If I have to recommend something to improve the care I’m receiving, this will be for the healthcare provider to develop good communication with their patients so as to let them understand what is going on with their disease and help them engage in the care." (Patient, Female, 5 years with diabetes)

One participant stressed that for good glycaemic control, this communication has to be extended to all significant persons to the patient as they can interfere or influence the management and outcomes. He also suggested that regular home visits be performed to gain deeper understanding of the patient’s social context:

"If they had (the) financial means, we would also do home visits and arrive where the patients live with their families, since these are elements that we do not know. These elements can help us in finding solutions to the challenges raised in the care of these patients." (Generalist, Male, 15 years of experience)

An important issue in this process, is education for behavioural change. The adherence to what is prescribed by the healthcare providers is essential for better outcomes.

"Yes, if you do not respect what is prescribed, you will have complications." (Patient, Female, 15 years of diabetes)

One participant raised the importance of patents respecting the follow-up scheduled appointments for healthcare providers to act appropriately and avoid clinical inertia.

"Today, there is a lot of talk about therapeutic inertia, that is to say not acting when it is necessary or not increasing the dose of a drug that the patient is following or not adding another drug when necessary. Acting appropriately is difficult if the patient does not keep appointments." (Diabetologist, Male, 12 years of experience)

Participants also explained how they use what is within their reach (technology) to help with adherence to treatment. One participant explained using the phone alarm to remember times when he was taking medication:

"I make an effort to take the medication as prescribed. I use my phone alarm to remind me of medication times." (Patient, Female, 7 years of experience)

Theme 2: Supporting the patients and the population

This theme describes the actions for supporting the patients with diabetes to cope and succeed in reaching a good glycaemic control. These actions concern the patients, their families, the health providers, and the community.

Community sensitization about diabetes

One participant expressed that for a person to seek care for diabetes, he must be informed about diabetes mellitus. Unfortunately, the population has little knowledge about diabetes and there is no sensitization of the population unlike other diseases such as malaria and HIV. The participants recommended that the population must be informed about diabetes:

"I think we need a campaign to raise awareness or educate the population. The lack of information contributed to the deaths of many people." (Patient, Male, 20 years of diabetes)

Patients have many questions about the origin of the disease, especially at the beginning of the disease. When all these concerns are not well addressed, they may abandon treatment and move on to other alternatives:

"Patients who do not receive good information about their disease will orientate themselves to alternative medicine." (Diabetologist, Male, 12 years of experience)

The participants noted that there are many negative influences in the surroundings of the patients with diabetes. Many messages broadcasted by radio and televisions by people claiming they could cure the disease. These messages motivate patients to seek for alternative treatments. There is need for accurate information for the patients:

"It is also crucial to fight against those charlatans coming with illusions saying that they can cure diabetes, and spreading messages through mass media." (Nurse, Female, 25 years of experience)

Involving families as support system to patients

Several participants reported that it is important to involve families in the care of their family members. They found that this was of interest not only to the extent that families could help to lighten the burden of care, but also to encourage patients to follow their treatments:

"My experience is that when the parents have diabetes, their elderly children respond favorably to our call and act to find a way to support their parents; when the sick persons is a brother or a sister, assistance (support) is more difficult to get from their relatives." (Family physician, Male, 5 years of experience)

"To improve blood sugar control, it is important to involve family members, because they are the ones who surround him more closely, help him to heal himself or to overcome difficulties." (Nurse, Female, 17 years of experience)

Theme 3: Adopting supportive policies

This theme describes supportive policies required in the healthcare setting to facilitate the move to better glycaemic control.

Fight against poverty to address socioeconomic disparities

The lack of resources condition many, if not all, the aspects of diabetes care. From the organisation of care in the health system to the capacity of the patients to adequate adherence to the treatment prescribed by the healthcare providers, through the motivation of healthcare providers to be engaged in this activity.

"It is important that health providers be motivated for diabetes care." (Generalist, Male, 5 years of experience)

One participant suggested that the patients should be empowered in the term of financial capacity:

"Patients do not know how to follow their treatments well if they are food insecure. Government action should also aim at improving food security." (Diabetologist, Male, 14 years of experience)

Other participants expressed that the universal health coverage be implemented to alleviate the financial burden of diabetes for the patients and their families”:

"Usually the patients are offered a limited range of products, new anti hypoglycaemic agents or even the new insulins are above the revenue (the reach) of many patients. This is the place where health financing must intervene within universal health coverage or health insurance or health mutuals." (Diabetologist, Male, 12 years of experience)

""Yes, it is essential that diabetes, which is a chronic pathology, is covered by a health insurance which renders the process of care easier." (Nurse, Female, 9 years of experience)

Effective financing of diabetes care

Participants expressed that the Government has to play key roles in improving diabetes care and consequently, glycaemic control. One of these roles consists in ensuring that the health system is strengthened with a functioning and efficient National Program of diabetes and by guarantying all the activities dedicated to the fight against diabetes be supported.

Participants noticed a lack of distributive justice and called for equity in the distribution of health resources particularly in diabetes care:

"The Government must revise its lists of health priorities; diabetes might (should) be put at the same levels as malaria, tuberculosis and HIV/AIDS." (Generalist, Male, 5 years of experience).

"In current situation without health insurance, if they have not a good source of revenue, patients with diabetes are condemned to poverty and poor health outcomes." (Patient, Male, 20 years of diabetes)

Support activities for prevention of diabetes

Safe lifestyle counts much in the prevention of diabetes. In Kinshasa, there is a tendency for inhabitants to adopt fast-foods that are mainly sweetened beverages and cholesterol-rich foods. The consumption of these products are supported by the wide spread advertising spots on the streets, radio and televisions. The Government must engage itself in promoting primary prevention of diabetes by discouraging the consumption of unhealthy diets or even by acting against the manufacturers of these products:

"It is important to regulate the manufacture and consumption of sugar-sweetened beverages. Another measure would be to look (screen) for diabetes in patients with high risk of cardiovascular disease." (Diabetologist, Male, 14 years of experience)

Multidisciplinary approach

There is a need for a multidisciplinary approach to the management of diabetes in Kinshasa. Many diabetic patients have shown denial at diagnosis. Sometimes, patients do not understand that diabetes is a chronic disease requiring continuous care, they are tired and often neglect treatment. There is a need for psychological support in the management of diabetes. There are some contradictions that have been found in the recommendations made about the diets to patients with diabetes. There is a need for consensus between diabetologists and nutritionists in the message given to patients with diabetes. Creating a multidisciplinary team that acts in harmony with tasks that complement each other will be a major step forward in primary healthcare.

"Diabetologists have their own considerations of what they think is the appropriate diet for diabetic patients; these considerations are not the same as those of nutritionists and there are times when patients end up with prescriptions contrary to those we want." (Diabetologist, Male, 12 years of experience)

"General practitioners who work in healthcare facilities at the primary level of care do not have enough information to allow them properly care for patients. Sometimes they provide patients with information that is outright at odds with what we want to take care of." (Diabetologist, Male, 14 years of experience).

This study aimed to describe the perspectives of healthcare providers and patients with type 2 diabetes on improving glycaemic control in Kinshasa, DRC. Three themes emerged as perspectives from healthcare providers and patients to improve glycaemic control: Strengthening the healthcare system, supporting patients and their communities, and adopting supportive healthcare policies.

The improvement of glycaemic control involves actions from patients and their families, healthcare organisations, the community, and the policy environment such that: patients are empowered for self-management through a patient-provider relationship that is patient-centred; the care provided to patients with diabetes should be evidence-based and by multidisciplinary healthcare teams in well-equipped healthcare facilities; at the community level, psychosocial support should be provided to patients with diabetes and people’s knowledge on diabetes improved; and at the policy level, multipronged primary prevention program of diabetes and effective healthcare financing should be assured.

Glycaemic control could not be achieved without strengthening the healthcare system and this includes ensuring that the evidence-based care of diabetes is managed by trained staff working in well-equipped healthcare structures and the supplies are adequately organized. [32]. An assessment of the Kinshasa Healthcare Network in relation to diabetes care found that the capacities, knowledge, and practice of type 2 diabetes care was poor [33]. Our study findings align with these authors’ recommendations that the capacity of health facilities should be improved by providing necessary equipment, training of healthcare providers and implementing task shifting to other cadres where there is scarcity of medical doctors in primary healthcare facilities. To achieve these, better healthcare financing is required, including exploring public-private partnerships [34]. An efficient national diabetes program is also needed to put pressure on the government and society to recognize the level of threat diabetes poses on the wellness, quality of life and productivity of the population. This advocacy program requires better organisation of data which can feedback into the diabetes management guidelines, with clear description of the roles of stakeholders for better diabetes care outcomes. Furthermore, community-level organizations including community health workers should be utilized for health education and campaigns, and to connect patients and their households to the continuum of diabetes care provided within healthcare facilities. Such continuous and patient-centred program and approach has been previously recommended for better health outcomes [35].

Diabetes care is costly and costs per person are much higher than in the general population [36]. In Kinshasa, most patients are uninsured and rely on out-of-pocket payment with significant risk for poor treatment adherence and glycaemic control [37]. To this end, a systematic review on the influence of health system on type 2 diabetes recommended reducing or even elimination out-of-pocket payments [38] and in the light of the WHO recommendations, the government of the DRC must explore extending health insurance to those who are socioeconomically vulnerable by implementing universal health coverage [39]. For sustainability, there is a need to improve the financial capacity of population through educational and socioeconomic programs aimed at developing the knowledge and skill base of the population and wealth creation and redistribution that fights endemic poverty.

Participants reported that costs influenced access and compliance to care [36]. This could be partly addressed in Kinshasa, through a public-private partnership within the pharmaceutical sector to reduce costs by producing generic formulations and so, help create an affordable and reliable drug delivery system. A study in Nigeria found that the integration of generic medicines into routine care as element of a partnership with the pharmaceutical private sector could help to reduce the burden of medications [40].

Healthy lifestyle such as low calorie and fat diets, regular exercise, moderate alcohol consumption and smoking cessation, reduce the risk of developing type 2 diabetes [41–43] and should be emphasized by public health programs. Unfortunately, there are no evidence-based local implementation science studies that inform the best ways of implementing lifestyle changes at individual and population levels in the DRC or Kinshasa. Lifestyle programs must be integrated and consider available and affordable food stuff and regulation of “freezy” drinks in DRC, feasible exercise and physical activity plans in the community and workplace, and health policies that regulate alcohol and tobacco marketing, use and misuse [44–46].

In Kinshasa, DRC, like in most developing countries, undiagnosed or occult diabetes exists in high proportion, and patients are usually diagnosed in advanced stage when glycaemic control is a challenge [47, 48]. Although mass screening may be done, targeting people at high risk of diabetes for screening is more effective [49]. It is therefore important that healthcare providers utilize opportunities offered by the clinical encounter to screen for diabetes, mainly for individuals with a family history of diabetes, central obesity, increased age, and hypertension [50–52].

Self-care behaviours are correlated with improved glycaemic control [53] however, many barriers to self-management in patients with type 2 diabetes were reported by study participants. Healthcare providers reported that patients are of low educational level and that this interferes with their understanding of the health education messages shared with them. Indeed, as reported by Al-Rasheedi [54], educational level showed mixed results in relation with glycaemic control. Educational programs on diet, exercise and follow-up appointments were of greater benefit in glycaemic control than other aspects of care. Abdulah and colleagues [55] also found in a double-arm post-test intervention study that patients benefitted from three two-hour educational sessions on dietary habits and physical activity designed according to the Health Belief Model showed improvements in positive physical activity, dietary and biochemical indicators [55]. Group health education for patients with type 2 diabetes on knowledge, diet, and exercise also improved better glycaemic control compared to usual care [56]. Whether these intervention modalities would be beneficial in Kinshasa, DRC, is not known. Implementation science research is therefore needed to explore the feasibility, suitability and utility of these interventions in diabetes self-management in Kinshasa, DRC.

Several studies have shown that family support is associated with better glycaemic control [57, 58]. The family represent the place where the illness experience begins and is handled with support of significant people [59]. However, for this involvement to be helpful, family members must not be obstructive in their behaviours [60]. In this study, the family was reported by many participants as the sole source of emotional and financial support [61] and this needs to be recognized by healthcare providers as a strength, and used to formulate a family-oriented management approach for diabetes, particularly that this approach improves relatives’ understanding of the diseases and reduces their stress, anxiety and depression, and increases their satisfaction and relationship with healthcare providers [62].

The Democratic Republic of the Congo is one of the least developed countries globally with a quarter of its 26.4 million people acutely food insecure[63] and 62% living on less than $2.15 a day in the year 2022 [27]. Optimal glycaemic control at population level is difficulty to achieve in the face of these socioeconomic challenges. Poverty eradication and food security therefore need to be at the core of advocacy groups and government programs in the DRC, including in the national diabetes care program.

Participants who are healthcare providers reported in this study that advertisement by alternative healthcare practitioners carry misleading health messages:

"It is also crucial to fight against those charlatans coming with illusions saying that they can cure diabetes, and spreading messages through mass media." (Nurse, Female, 25 years of experience)

There is therefore a need to regulate the advertisement of healthcare services, particularly by alternative healthcare practitioners in Kinshasa, as it is not unusual that they disperse misleading messages about diabetes and its treatment through mass media [64]. Patients with type 2 diabetes are vulnerable and promises that are not evidenced-based shared by these practitioners have potential to deter patients from adhering to medical treatment or even default, with serious consequences. Promotion of evidence-based health information by community-based diabetes advocacy groups can assist patients with diabetes not to accept false messages and prevent the untoward consequences of default of treatment [65].

Creating a multidisciplinary team at the primary care of level will be useful, as it is at this level of care that most patients with type 2 diabetes are attended and considering the natural evolution of diabetes management from lifestyle changes to the prevention of cardiovascular and/or microvascular complications [66]. The multidisciplinary team model has been linked to improved diabetes treatment outcomes and helps in preventing and reducing complications [67]. Nevertheless, poor interactions between categories of healthcare providers can interfere with the quality of patient care [68]. The multidisciplinary team at the primary care of care must therefore be constructed and trained to provide care to patients with type 2 diabetes in an integrative manner within the framework of managing all non-communicable diseases.

Since improving blood glucose control in patients with type 2 diabetes requires an improvement in the healthcare system, it would be wise to think, as recommended by the WHO [67], in a broader context of better preparedness of the health system not only for diabetes but for other non-communicable and communicable diseases. Figure 1 presents an explanatory model that integrates the themes that emerged from participants’ perspectives on improving glycaemic control among patients with type 2 diabetes in Kinshasa, DRC. This explanatory model is best understood using the Innovative care for chronic conditions Framework [24]. This framework was developed by WHO to adapt the use of chronic care model in low- and middle-income countries. It recognizes three levels of care (micro, meso and macro) and incorporates six principles: evidence-based decision making, population focus, prevention focus, quality focus, integration, flexibility, and adaptability. In our study, the micro level comprises of the patients and their families, the meso level is represented by the health system organisation and the community, and the macro level comprises of the policy environment.

Figure 1 Explanatory model: Improving glycaemic control among patients with type 2 diabetes. Adapted from the WHO Innovative care model for chronic diseases (WHO, 2002).

At the micro level, a strong healthcare provider-patient relationship facilitates communication in a patient-centred way and encourages self-management, improving patients’ positive experience of their own disease and its care. At the meso level, diabetes care needs to be evidence-based and provided by trained healthcare providers within healthcare facilities that are well-equipped and supported by a reliable drug delivery system. In the community, mass, group and individual education on diabetes improve patients’ and relatives’ knowledge of diabetes and ensures positive support is provided to the patients by their families and relatives. At the macro level, appropriate measures should be taken to ensure primary prevention of diabetes, fight poverty and promote food security, regulation of healthcare advertising for “truthful” health messaging, public healthcare financing that promotes universal coverage, and multidisciplinary team approach to diabetes care. All these actions when implemented in an integrated way have potential to improve glycaemic control among patients with type 2 diabetes in Kinshasa, DRC.

We would like to allude to some strengths and limitations in this study: This was the first qualitative study to explore both the perspectives of patients with type 2 diabetes and healthcare providers on improving glycaemic control in sub-Saharan Africa and its findings have implications for health policy, diabetes clinical practice, health systems organization and future research in diabetes in this setting, particularly in the DRC. Furthermore, the credibility of the study findings was enhanced by the multi-source triangulation, from patients from different socioeconomic backgrounds and healthcare providers with various levels of expertise in diabetes care. Nevertheless, there is potential for information and interpretation biases, as social desirability on the part of some participants and researcher’s preconceptions, could have influenced participants’ responses and data analysis respectively. These were addressed by prior training of the interviewer in qualitative methods to the end that the interviewer adopted a neutral attitude during the interviews and was aware of his own preconceptions, preventing them from influencing him during data analysis. Also, creating a free and non-judgmental interview environment enabled participants to give their perspectives, unhindered. Although a selection bias could have resulted from the purposive sampling, health professionals in the different care facilities were the ones that identified the patients most likely to share their experiences. Triangulation of findings with other investigators, external review by two experts and audits of the data and research processes by the research supervisors, all enhanced the credibility of the study findings. While the study findings cannot be generalized (imposed by the qualitative design), the findings are transferable, and therefore useful in informing the development of programmatic frameworks and interventions aimed at improving glycaemic control among patients with type 2 diabetes in the DRC, sub-Saharan Africa and similar settings.

COREQ

Consolidated criteria for reporting qualitative research

DRC

Democratic Republic of the Congo

HIV/AIDS

Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrom

JPF

Jean-Pierre Fina

OBO

Olufemi Babatunde Omole

WHO

The World Health Organization

Ethics approval

This study was conducted after the approval from the ethics committees of the Protestant University of Congo (reference number: CEUPC 0067; Date: 05/02/2021) and Human Research Ethics Committee (Medical) of the University of the Witwatersrand (reference number: M210308; Date: 26/08/2021). The study was conducted according to the ethical guidelines of the Declaration of Helsinki. Permission was obtained from the Kinshasa Primary HealthCare Network to conduct the study. Informed consent was obtained from each participant.

Consent for publication

Informed consent was obtained from each participant.

Availability of data and materials

The transcripts of our study can be provided upon reasonable request to the corresponding author.

Competing interests

The authors declare that they have no competing interests.

Funding

The authors received no specific funding for this work.

Authors’ contributions

JPF conceived the study, conducted the interviews, contributed to the translation of the transcripts to English, performed analysis, and wrote the first draft of the manuscript. JMF contributed to the conceptualization and operationalization of the study and reviewed the manuscript. OBO contributed to the conceptualisation and operationalization of the study, analysis, and reviewed the manuscript. All the authors agreed with the final draft of the manuscript.

Acknowledgements

The authors are grateful to all the staff and patients of the Kinshasa Primary Health Network and other facilities for their support and cooperation during the study.

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No competing interests reported.

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Perspectives of healthcare providers and patients with type 2 diabetes mellitus on improving glycaemic control in Kinshasa, Democratic Republic of the Congo: a qualitative study

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Background

Methods

Study design

Theoretical framework

Study setting

Study population and sample

Data collection

Data management and analysis

Credibility, transferability, dependability, and confirmability

Results

Theme 1: Strengthening the healthcare system

(Diabetologist, Male, 12 years of experience)

Theme 2: Supporting the patients and the population

Theme 3: Adopting supportive policies

Discussion

Conclusions

Abbreviations

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