Assessing service availability and readiness of healthcare facilities to manage diabetes mellitus in Bangladesh: Findings from a nationwide survey

Diabetes care cascade in Bangladesh: Identifying gaps and social determinants

AIMS

Precise and up-to-date data regarding the care gaps is essential to prioritize interventions and guide efficient resource allocation for management of diabetes in Bangladesh. The aim of the present study was to evaluate the diabetes care cascade and identify the social determinants influencing retention at each stage of care in Bangladesh.

METHODS

Data was extracted from Bangladesh Demographic and Health Survey (BDHS), 2022. Type 2 diabetes mellitus (T2DM) was defined as fasting blood glucose ≥7.0 mmol/L or a diagnosis by a healthcare provider. The care cascade comprised three stages: (i) diagnosis, (ii) receiving treatment, and (iii) glycemic control. Logistic regression and Andersen's Behavioral Model were used in the study.

RESULTS

Among 2,403 individuals with T2DM, 33.5 % were diagnosed, 24.6 % received treatment, and 9.6 % achieved glycemic control. Losses occurred at diagnosis (66.5 %), treatment (9 %), and control (19.6 %). Women, individuals with higher education, and those in the wealthiest quintile had higher odds of diagnosis. Receiving treatment was significantly associated with wealth and body mass index.

CONCLUSIONS

Significant gaps were observed at all stages of diabetes care cascade, particularly diagnosis. Strengthening screening, ensuring access to affordable treatment, and improving adherence are essential to enhance glycemic control and mitigating the diabetes burden.

Barriers to treatment seeking for depression among elderly service users at Butabika National Referral and Teaching hospital, Kampala- Uganda

OBJECTIVES

Depression among the elderly is a significant public health concern in Uganda, where cultural, social, and healthcare-related barriers hinder access to treatment and support. This study examines the barriers to mental health service access faced by elderly service-users in Uganda.

METHOD

Using an interpretive phenomenological approach, in-depth interviews were conducted to capture the lived experiences of elderly Baganda service users receiving treatment at Butabika National Referral and Teaching hospital.

RESULTS

The findings reveal an intricate interaction between cultural, social, economic, and healthcare system-related barriers. Key barriers include limited mental health awareness, financial constraints, fragmentation, drug shortage and geographical access. Social and cultural stigma further exacerbate these challenges contributing to delayed or avoided help-seeking behaviours among the elderly.

CONCLUSION

The study highlights the intersectionality of aging and mental health issues, underscoring the urgent need for a comprehensive, integrated approach to mental health care for the elderly. This research calls for targeted interventions to reduce stigma, increase mental health literacy, and improve the accessibility and affordability of care for vulnerable elderly populations in Uganda. Such services can improve mental health outcomes and quality of life for the elderly in Uganda.

Healthcare facility readiness and availability for hypertension and type 2 diabetes care in Puno, Peru: a cross-sectional survey of healthcare facilities

BACKGROUND

Non-communicable diseases are a rapidly growing cause of mortality and morbidity in Peru, accounting for 73% of total deaths. There is limited research on health system readiness to manage this rising burden. Our study characterized the readiness of healthcare facilities to manage patients with hypertension and/or type 2 diabetes (T2D) across two public healthcare systems in Puno, a largely rural and low-income department in Peru.

METHODS

We adapted the World Health Organization Service Availability and Readiness Assessment to characterize resources and services for hypertension and T2D care. We administered the survey to personnel at healthcare facilities in Puno. Service readiness scores were calculated based on tracer items necessary for hypertension or T2D care. Facilities with ≥ 70% of tracer items were considered ready to manage each disease.

RESULTS

Between June 2022 and June 2023, we surveyed 85% (414/488) of Puno's government-run healthcare facilities. Overall, only 28% and 29% were considered ready to manage hypertension and T2D, respectively. Despite larger annual cumulative case volumes at health posts and low-level health centers, lower-level facilities were significantly less likely to be ready to manage hypertension (OR = 0.20, 95% CI 0.11-0.36) or T2D (OR = 0.03, 95% CI 0.01-0.06). Areas of concern included an overreliance on aneroid blood pressure monitors, their infrequent calibration, and limited hemoglobin A1c and urine testing. Additionally, only 66% and 48% of providers self-reported that they could diagnose hypertension and T2D, respectively. There was also low essential medication availability including insulin (7.2%) and fixed-dose combinations (0.5%) and a scarcity of trained healthcare professionals, particularly community health workers at health posts (49.8% had none).

CONCLUSIONS

Healthcare facilities were largely unprepared to manage hypertension and T2D, underscoring the critical need for health system strengthening to address disparities in non-communicable disease management across Puno.

Service availability and readiness of tuberculosis units' clinics to manage diabetes mellitus in Lubumbashi, Democratic Republic of the Congo

INTRODUCTION

In low-income countries such as the Democratic Republic of the Congo (DRC), the strategies implemented to combat tuberculosis (TB) are threatened by the emergence of non-communicable diseases (NCDs), such as diabetes mellitus (DM). Very little data on the implementation of services to manage TB-DM are generally available in these low-income countries. The aim of this study was therefore to assess the level of implementation of DM screening and treatment activities in TB unit clinics (TUCs) in Lubumbashi, DRC.

METHODS

A cross-sectional study was conducted using the Service Availability and Readiness Assessment (SARA) questionnaire from June to July 2023. Fourteen tracer items, divided into 4 domains-i) guidelines and staff, ii) basic equipment, iii) diagnostic capacity, and iv) drugs and products-were assessed. The readiness indices were compared according to the managerial instance and the activity package organized in each of the selected TUCs. A Chi2 test with a significance level set at p = 0.05 was used for this comparison, and Cronbach's α coefficient was calculated to estimate the reliability or consistency of the questionnaire.

RESULTS

Of the 35 TUCs visited, 19 (54.3%) were public health facilities, and 20 (57.1%) had a supplementary package of activities (SPA). The readiness of TUCs for providing DM diagnostic and treatment services was around 50%. A statistically significant difference was observed based on the managerial instance overseeing the TUC (p = 0.00) and the package of activities offered within these institutions (p = 0.00).

CONCLUSION

The current study has underscored the limited capability of TUCs in Lubumbashi to provide services for managing TB-DM comorbidity in DRC. It is imperative to implement strategies aimed at enhancing this capacity and taking into account the local context and influencing factors.

Factors influencing type 2 diabetes self-management practices in rural Bangladesh: a qualitative investigation

Introduction

Type 2 diabetes mellitus (T2DM) is a prevalent, chronic health condition of global significance, with low- and middle-income countries (LMICs) disproportionately affected. Diabetes self-management practices (DSMP) are the gold-standard treatment approach, yet uptake remains challenge in LMICs.

Purpose of the study

This study aimed to explore the barriers to and facilitators of DSMP and preferences for intervention design and delivery in Bangladesh, an LMIC, with prevalent T2DM.

Methods

Sixteen qualitative focus group discussions (FGDs) with adults with T2DM and their caregivers were conducted in rural Bangladesh to explore preferences, barriers, and facilitators for community DSMP-related intervention programs. Data were thematically analyzed using a deductive theoretical domains framework (TDF) underpinned by the socio-ecological model.

Results

Overall, 117 participants (n = 58 with T2DM and n = 59 caregivers) were included in the analysis. Five overarching themes were identified, including (i) implementation of DSMP, (ii) community spirit and interconnectedness, (iii) environmental influences, (iv) healthcare professionals' role in DSMP, and (v) government support. Key barriers to DSMP identified for T2DM patients include knowledge implementation gaps, cultural practices, limited resources, and financial constraints. Facilitators include motivation, support from family and peers, and religious practices. Rural Bangladeshis prefer programs delivered at community clinics, viewing them as reliable, culturally appropriate central 'hubs' to assemble.

Conclusion

Barriers to and facilitators of DSMP were identified, and preferences for intervention design and delivery for implementing DSMP were explored. The findings provide a foundation for the critical need to implement programs that improve DSMP in Bangladesh, with the potential to translate to other LMIC settings.

Health Services Availability and Readiness for Management of Hypertension and Diabetes in Primary Care Health Facilities in Ghana: a Cardiovascular Risk Management project

Introduction

Hypertension and diabetes are leading causes of adult hospital admissions and mortality across health facilities in Ghana. Timely screening and diagnosis at primary health facilities are crucial to initiate treatment and avert complications. This study explored service availability and readiness of health systems for managing hypertension and diabetes in selected district hospitals in Ghana.

Methods

We adapted the World Health Organization (WHO) Service Availability and Readiness Assessment (SARA) tool to assess hypertension and diabetes management practices between June and July 2022 in four district hospitals in Ghana. Domain scores of service readiness were calculated based on the mean score of tracer item availability, transformed into percentages, and stratified by facility ownership. The mean readiness index was based on basic clinical logistics and equipment, diagnostic capacity, and first-line medications. Service availability was based on the core health workforce and specific service arrangements for the management of hypertension and diabetes. Facilities were considered 'ready' for services at a cut-off readiness score of 70%.

Results

All facilities (n = 4, 100%) provided hypertension and diabetes services, with a median of 118 nurses (IQR 103-140) and 5 physicians (IQR 2-8). Only one facility (n = 1, 25%) had conducted cardiovascular disease training in the past year. All basic equipment (weighing scales, stethoscopes, glucometers, and blood pressure monitors) were available in all 4 facilities. Antihypertensives, including ACE inhibitors (n = 3; 75%), calcium channel blockers (n = 4; 100%), centrally acting agents (n = 4; 100%), and thiazides (n = 4; 100%), were available, as were antidiabetic medications like metformin (n = 4; 100%) and insulin (n = 2; 50%). Only two facilities (n = 2; 50%) could perform the required test (Hemoglobin A1c, full blood count, renal function, serum creatinine, blood urea, electrolytes, and blood lipid tests). Overall readiness score was 75.5%, essential medications (83.5%), basic equipment (78%), clinical guidelines for the management of cardiovascular disease management (75%), and diagnostic capacity (65.5%). Mission facilities had a higher readiness score (96%) and government facilities (55%).

Conclusion

Facilities demonstrated high readiness for basic hypertension and diabetes care, with higher availability of some essential medications and basic clinical logistics and equipment. Limited diagnostic capacity and cardiovascular disease training, highlight areas of improvement to strengthen hypertension and diabetes services in Ghana.

An approach to integrated management of diabetes in tuberculosis patients: Availability and readiness of the health facilities of Bangladesh

BACKGROUND

Comorbidity of diabetes mellitus and tuberculosis (TB) is a major public health concern in low- and middle-income countries including Bangladesh. An integrated approach is required for adequate management of diabetes mellitus and TB. The objective of the present study was to investigate the availability and readiness of the TB care centers of Bangladesh toward diabetic patients' management.

METHODS

The present study was conducted based on existing data obtained from the Bangladesh Health Facility Survey (BHFS) 2017. Data collected from a total of 303 facilities providing TB services were retrieved. The outcome variables of the present study were availability and readiness of the TB health facilities for providing diabetes mellitus service. Readiness was measured for four domains: staff and guidelines, equipment, diagnostic facility and basic medicine. The independent variables were: facility level, management authority and location of the facility. Binary and multiple logistic regression models were constructed for both the outcome variables (availability and readiness) to find out their predictors.

RESULTS

Services for diabetes mellitus were available in 68% of the TB facilities while high readiness was present in 36% of the facilities. For domain-specific readiness index, readiness for the domains of staff and guidelines, equipment, diagnostic facility and basic medicine was reported in 46%, 96%, 38% and 25% facilities respectively. In the logistic regression model, availability of diabetes mellitus services was better in primary level (aOR 2.62, 95% CI 1.78-4.77) and secondary level (aOR 3.26, 95% CI 1.82-9.05) facilities than community facilities. Similarly, readiness of diabetes mellitus care was also better in these facilities (aOR 2.55, 95% CI 1.05-4.71 for primary and aOR 2.75, 95% CI 1.80-4.32 for secondary facilities). Besides, private TB facilities had better availability (aOR 2.84, 95% CI 1.75-5.89) and readiness (aOR 2.52, 95% CI 1.32-4.29) for diabetes mellitus care.

CONCLUSION

Availability and readiness for providing diabetes mellitus services in TB care providing facilities in Bangladesh is inadequate.

Exploring type 2 diabetes self-management practices in rural Bangladesh: facilitators, barriers and expectations-a qualitative study protocol

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a global public health crisis impacting low-income and middle-income countries such as Bangladesh. While self-management is encouraged for individuals with T2DM, there is a significant lack of knowledge regarding the factors of facilitators, barriers and expectations associated with T2DM self-management in Bangladesh. This research aims to investigate the potential elements that support, impede and are anticipated in the effective practice of self-management for T2DM in rural areas of Bangladesh.

METHODS AND ANALYSIS

This study will use an exploratory qualitative approach. 16 focus group discussions, 13 in-depth interviews and 9 key informant interviews will be conducted among multilevel stakeholders, including people with T2DM, their caregivers, healthcare providers, health managers/administrators and policy planners. Interviews will be audio-recorded, transcribed, translated and analysed using thematic analysis.

ETHICS AND DISSEMINATION

This research project has been approved by the Monash University Human Research Ethics Committee (project reference number: 39483) and the Ethical Review Committee of the Centre for Injury Prevention and Research, Bangladesh (Memo: CIPRB/ERC/2023/14). Research findings will be disseminated in peer-reviewed journals and conference presentations. Published reports will include group data. Individual data privacy will be strictly maintained.

Enhancing care quality and accessibility through digital technology-supported decentralisation of hypertension and diabetes management: a proof-of-concept study in rural Bangladesh

OBJECTIVE

The critical shortage of healthcare workers, particularly in rural areas, is a major barrier to quality care for non-communicable diseases (NCD) in low-income and middle-income countries. In this proof-of-concept study, we aimed to test a decentralised model for integrated diabetes and hypertension management in rural Bangladesh to improve accessibility and quality of care.

DESIGN AND SETTING

The study is a single-cohort proof-of-concept study. The key interventions comprised shifting screening, routine monitoring and dispensing of medication refills from a doctor-managed subdistrict NCD clinic to non-physician health worker-managed village-level community clinics; a digital care coordination platform was developed for electronic health records, point-of-care support, referral and routine patient follow-up. The study was conducted in the Parbatipur subdistrict, Rangpur Division, Bangladesh.

PARTICIPANTS

A total of 624 participants were enrolled in the study (mean (SD) age, 59.5 (12.0); 65.1% female).

OUTCOMES

Changes in blood pressure and blood glucose control, patient retention and patient-visit volume at the NCD clinic and community clinics.

RESULTS

The proportion of patients with uncontrolled blood pressure reduced from 60% at baseline to 26% at the third month of follow-up, a 56% (incidence rate ratio 0.44; 95% CI 0.33 to 0.57) reduction after adjustment for covariates. The proportion of patients with uncontrolled blood glucose decreased from 74% to 43% at the third month of follow-up. Attrition rates immediately after baseline and during the entire study period were 29.1% and 36.2%, respectively.

CONCLUSION

The proof-of-concept study highlights the potential for involving lower-level primary care facilities and non-physician health workers to rapidly expand much-needed services to patients with hypertension and diabetes in Bangladesh and in similar global settings. Further investigations are needed to evaluate the effectiveness of decentralised hypertension and diabetes care.

Diabetes health care specific services readiness and availability in Kenya: Implications for Universal Health Coverage

Diabetes is a major cause of morbidity and mortality worldwide yet preventable. Complications of undetected and untreated diabetes result in serious human suffering and disability. It negatively impacts on individual's social economic status threatening economic prosperity. There is a scarcity of data on health system diabetes service readiness and availability in Kenya which necessitated an investigation into the specific availability and readiness of diabetes services. A cross sectional descriptive study was carried out using the Kenya service availability and readiness mapping tool in 598 randomly selected public health facilities in 12 purposively selected counties. Ethical standards outlined in the 1964 Declaration of Helsinki and its later amendments were upheld throughout the study. Health facilities were classified into primary and secondary level facilities prior to statistical analysis using IBM SPSS version 25. Exploratory data analysis techniques were employed to uncover the distribution structure of continuous study variables. For categorical variables, descriptive statistics in terms of proportions, frequency distributions and percentages were used. Of the 598 facilities visited, 83.3% were classified as primary while 16.6% as secondary. A variation in specific diabetes service availability and readiness was depicted in the 12 counties and between primary and secondary level facilities. Human resource for health reported a low mean availability (46%; 95% CI 44%-48%) with any NCDs specialist and nutritionist the least carder available. Basic equipment and diagnostic capacity reported a fairly high mean readiness (73%; 95% CI 71%-75%) and (64%; 95%CI 60%-68%) respectively. Generally, primary health facilities had low diabetic specific service availability and readiness compared to secondary facilities: capacity to cope with diabetes increased as the level of care ascended to higher levels. Significant gaps were identified in overall availability and readiness in both primary and secondary levels facilities particularly in terms of human resource for health specifically nutrition and laboratory profession.

Availability and readiness of the health facilities to provide HIV counseling and testing and prevention of mother-to-child transmission services in Burkina Faso: a trend analysis from 2012 to 2018

BACKGROUND

Provider-Initiated HIV Testing and Counseling (PITC) and Prevention of Mother-To-Child Transmission (PMTCT) are key services for achieving the goal of complete elimination of HIV. However, there is limited evidence on the ability of health facilities to provide these services in Burkina Faso. Therefore, we aimed to assess the trends and disparities in the availability and readiness of health facilities to provide PITC and PMTCT services in Burkina Faso between 2012 and 2018.

METHODS

We performed a secondary analysis of facility-level data from the World Health Organization's Service Availability and Readiness Assessment (SARA) surveys conducted in 2012, 2014, 2016, and 2018 in Burkina Faso. The availability and readiness of health facilities were assessed using SARA's manual, and linear regressions were used to examine trends.

RESULTS

Between 2012 and 2018, the mean proportion of health facilities providing PITC services increased, but not significantly, from 82.9% to 83.4% (p = 0.11), with the mean readiness index significantly decreasing from 71.5% to 65.4% (p < 0.001). This decrease concerned the staff and guidelines (73.8% to 50.5%; p < 0.001), equipment (79.0% to 77.4%; p < 0.001), and medicines and commodities (54.2% to 45.2%; p < 0.001) domains. Regarding the PMTCT services, the mean proportion of health facilities globally providing the service significantly decreased from 83.7% in 2012 to 67.7% (p = 0.030) in 2018, and the mean readiness significantly decreased from 53.2% in 2012 to 50.9% in 2018 (p = 0.004). This decreasing trend was related to the staff and training (80.3% to 57.6%; p < 0.001) and medicines and commodities (9.2% to 6.5%; p < 0.001) domains. The global significant negative trend of readiness was mainly observed at the primary level of healthcare (52.7% to 49.4%; p = 0.030). Four regions experienced a significant decrease in the readiness index of health facilities to provide PMTCT services: Cascades, Centre, Centre-Sud, and Sud-Ouest, while Haut-Bassins and Nord regions showed increasing trends.

CONCLUSION

Availability and readiness of health facilities to provide PITC and PMTCT remain suboptimal in Burkina Faso. Actions to strengthen the skills of professionals and enhance the availability of medicines and commodities while focusing more on health regions with significant decreasing trends are urgently needed to improve the quality of services for HIV.

Readiness of health facilities to provide services related to non-communicable diseases in Nepal: evidence from nationally representative Nepal Health Facility Survey 2021

OBJECTIVE

To assess the readiness of public and private health facilities (HFs) in delivering services related to non-communicable diseases (NCDs) in Nepal.

METHODS

We analysed data from nationally representative Nepal Health Facility Survey 2021 to determine the readiness of HFs for cardiovascular diseases (CVDs), diabetes mellitus (DM), chronic respiratory diseases (CRDs) and mental health (MH)-related services using Service Availability and Readiness Assessment Manual of the WHO. Readiness score was measured as the average availability of tracer items in per cent, and HFs were considered 'ready' for NCDs management if they scored ≥70 (out of 100). We performed weighted univariate and multivariable logistic regression to determine the association of HFs readiness with province, type of HFs, ecological region, quality assurance activities, external supervision, client's opinion review and frequency of meetings in HFs.

RESULTS

The overall mean readiness score of HFs offering CRDs, CVDs, DM and MH-related services was 32.6, 38.0, 38.4 and 24.0, respectively. Guidelines and staff training domain had the lowest readiness score, whereas essential equipment and supplies domain had the highest readiness score for each of the NCD-related services. A total of 2.3%, 3.8%, 3.6% and 3.3% HFs were ready to deliver CRDs, CVDs, DM and MH-related services, respectively. HFs managed by local level were less likely to be ready to provide all NCD-related services compared with federal/provincial hospitals. HFs with external supervision were more likely to be ready to provide CRDs and DM-related services and HFs reviewing client's opinions were more likely to be ready to provide CRDs, CVDs and DM-related services.

CONCLUSION

Readiness of the HFs managed by local level to provide CVDs, DM, CRDs and MH-related services was relatively poor compared with federal/provincial hospitals. Prioritisation of policies to reduce the gaps in readiness and capacity strengthening of the local HFs is essential for improving their overall readiness to provide NCD-related services.

The capacity of primary healthcare facilities in Bangladesh to prevent and control non-communicable diseases

BACKGROUND

The rapid rise of non-communicable diseases (NCDs) has become a significant public health concern in Bangladesh. This study assesses the readiness of primary healthcare facilities to manage the following NCDs: diabetes mellitus (DM), cervical cancer, chronic respiratory diseases (CRIs), and cardiovascular diseases (CVDs).

METHODS

A cross-sectional survey was conducted between May 2021 and October 2021 among 126 public and private primary healthcare facilities (nine Upazila health complexes (UHCs), 36 union-level facilities (ULFs), 53 community clinics (CCs), and 28 private hospitals/clinics). The NCD-specific service readiness was assessed using the World Health Organization's (WHO) Service Availability and Readiness Assessment (SARA) reference manual. The facilities' readiness was assessed using the following four domains: guidelines and staff, basic equipment, diagnostic facility, and essential medicine. The mean readiness index (RI) score for each domain was calculated. Facilities with RI scores of above 70% were considered 'ready' to manage NCDs.

RESULTS

The general services availability ranged between 47% for CCs and 83% for UHCs and the guidelines and staff accessibility were the highest for DM in the UHCs (72%); however, cervical cancer services were unavailable in the ULFs and CCs. The availability of basic equipment was the highest for cervical cancer (100%) in the UHCs and the lowest for DM (24%) in the ULFs. The essential medicine for CRI was 100% in both UHCs and ULFs compared to 25% in private facilities. The diagnostic capacity for CVD and essential medicine for cervical cancer was unavailable at all levels of public and private healthcare facilities. The overall mean RI for each of the four NCDs was below the cut-off value of 70%, with the highest (65%) for CRI in UHCs but unavailable for cervical cancer in CCs.

CONCLUSION

All levels of primary healthcare facilities are currently not ready to manage NCDs. The notable deficits were the shortage of trained staff and guidelines, diagnostic facilities, and essential medicine. This study recommends increasing service availability to address the rising burden of NCDs at primary healthcare levels in Bangladesh.

Factor structure of the diabetes knowledge questionnaire and the assessment of the knowledge of risk factors, causes, complications, and management of diabetes mellitus: A national population-based study in Singapore

This study evaluated the knowledge of diabetes mellitus and predictors of the level of diabetes knowledge among the general public of Singapore. Confirmatory factor analysis and exploratory factor analysis were used to evaluate the fit of different factor models for the diabetes knowledge questionnaire. Multiple linear regressions were performed to determine the sociodemographic characteristics associated with diabetes knowledge. The final factor model identified three domains for diabetes knowledge: general knowledge, diabetes specific knowledge and causes of diabetes, and complications of untreated diabetes. Overall knowledge scores were 23.8 ± 2.4 for general diabetes knowledge, 2.3 ± 0.8 for diabetes specific knowledge, 2.3 ± 1.2 for causes, and 5.2 ± 1.2 for complications of untreated diabetes. Patients with diabetes were more knowledgeable than adults without diabetes in the population. While the general public in Singapore has adequate knowledge of diabetes, misconceptions were identified in both groups which underscores the need to tailor specific educational initiatives to reduce these diabetes knowledge gaps.