Hilde Bastiaens

Supporting diabetes self-management in primary care: Pilot-study of a group-based programme focusing on diet and exercise

AIMS To develop and implement a group self-management education programme for people with type 2 diabetes at the community level in primary care. This pilot-study intended to evaluate the feasibility, acceptability and long-term effects (12-18 months) of this programme on emotional distress, HbA1c, BMI and actual behaviour. METHODS An empowerment-based, theory-driven education programme was evaluated in a before-after design. The programme focused on behaviour assessment, goal-setting, problem solving and tailored information. A diabetes specialist nurse conjointly with a dietician or psychologist led five 2-hour sessions and a follow-up meeting after 3 months. RESULTS Forty-four people participated in 5 groups. BMI decreased with 0.45 kg/m(2) (95%CI 0.01-0.89) at 12-month and with 0.53 kg/m(2) (95%CI 0.02-1.04) at 18-month follow-up. HbA1c declined from 7.4% (+/-1.3) to 6.8% (+/-0.8) (p=0.040) and the PAID-score diminished from 28 (+/-20) to 18 (+/-13) (p=0.006) at 12-month post-intervention. These changes were only partly sustained at 18-month follow-up. Actual behaviour changed modestly. CONCLUSION Introducing the group education programme in primary healthcare is worthwhile (feasibility and effectiveness). A detailed description of the intervention is offered. Further research should explore the actual education process in greater depth.

Implementation of a program for type 2 diabetes based on the Chronic Care Model in a hospital-centered health care system: "the Belgian experience"

BackgroundMost research publications on Chronic Care Model (CCM) implementation originate from organizations or countries with a well-structured primary health care system. Information about efforts made in countries with a less well-organized primary health care system is scarce. In 2003, the Belgian National Institute for Health and Disability Insurance commissioned a pilot study to explore how care for type 2 diabetes patients could be organized in a more efficient way in the Belgian healthcare setting, a setting where the organisational framework for chronic care is mainly hospital-centered.MethodsProcess evaluation of an action research project (2003–2007) guided by the CCM in a well-defined geographical area with 76,826 inhabitants and an estimated number of 2,300 type 2 diabetes patients. In consultation with the region a program for type 2 diabetes patients was developed. The degree of implementation of the CCM in the region was assessed using the Assessment of Chronic Illness Care survey (ACIC). A multimethod approach was used to evaluate the implementation process. The resulting data were triangulated in order to identify the main facilitators and barriers encountered during the implementation process.ResultsThe overall ACIC score improved from 1.45 (limited support) at the start of the study to 5.5 (basic support) at the end of the study. The establishment of a local steering group and the appointment of a program manager were crucial steps in strengthening primary care. The willingness of a group of well-trained and motivated care providers to invest in quality improvement was an important facilitator. Important barriers were the complexity of the intervention, the lack of quality data, inadequate information technology support, the lack of commitment procedures and the uncertainty about sustainable funding.ConclusionGuided by the CCM, this study highlights the opportunities and the bottlenecks for adapting chronic care delivery in a primary care system with limited structure. The study succeeded in achieving a considerable improvement of the overall support for diabetes patients but further improvement requires a shift towards system thinking among policy makers. Currently primary care providers lack the opportunities to take up full responsibility for chronic care.Trial registration numberClinicalTrials.gov Identifier: NCT00824499

Effectiveness of the introduction of a Chronic Care Model-based program for type 2 diabetes in Belgium

BackgroundDuring a four-year action research project (2003-2007), a program targeting all type 2 diabetes patients was implemented in a well-defined geographical region in Belgium. The implementation of the program resulted in an increase of the overall Assessment of Chronic Illness Care (ACIC) score from 1.45 in 2003 to 5.5 in 2007. The aim of the follow-up study in 2008 was to assess the effect of the implementation of Chronic Care Model (CCM) elements on the quality of diabetes care in a country where the efforts to adapt primary care to a more chronic care oriented system are still at a starting point.MethodsA quasi-experimental study design involving a control region with comparable geographical and socio-economic characteristics and health care facilities was used to evaluate the effect of the intervention in the region. In collaboration with the InterMutualistic Agency (IMA) and the laboratories from both regions a research database was set up. Study cohorts in both regions were defined by using administrative data from the Sickness Funds and selected from the research database. A set of nine quality indicators was defined based on current scientific evidence. Data were analysed by an institution experienced in longitudinal data analysis.ResultsIn total 4,174 type 2 diabetes patients were selected from the research database; 2,425 patients (52.9% women) with a mean age of 67.5 from the intervention region and 1,749 patients (55.7% women) with a mean age of 67.4 from the control region. At the end of the intervention period, improvements were observed in five of the nine defined quality indicators in the intervention region, three of which (HbA1c assessment, statin therapy, cholesterol target) improved significantly more than in the control region. Mean HbA1c improved significantly in the intervention region (7.55 to 7.06%), but this evolution did not differ significantly (p = 0.4207) from the one in the control region (7.44 to 6.90%). The improvement in lipid control was significantly higher (p = 0.0021) in the intervention region (total cholesterol 199.07 to 173 mg/dl) than in the control region (199.44 to 180.60 mg/dl). The systematic assessment of long-term diabetes complications remained insufficient. In 2006 only 26% of the patients had their urine tested for micro-albuminuria and only 36% had consulted an ophthalmologist.ConclusionAlthough the overall ACIC score increased from 1.45 to 5.5, the improvement in the quality of diabetes care was moderate. Further improvements are needed in the CCM components delivery system design and clinical information systems. The regional networks, as they are financed now by the National Institute for Health and Disability Insurance (NIHDI), are an opportunity to explore how this can be achieved in consultation with the GPs. But it is clear that, simultaneously, action is needed on the health system level to realize the installation of an accurate quality monitoring system and the necessary preconditions for chronic care delivery in primary care (patient registration, staff support, IT support).Trial RegistrationTrial registration number: ClinicalTrials.gov Identifier: NCT00824499

Barriers to Condom Use among High Risk Men Who Have Sex with Men in Uganda: A Qualitative Study.

Background Unprotected sexual intercourse is a major risk factor for HIV transmission. Men who have sex with men (MSM) face challenges in accessing HIV prevention services, including condoms. However, there is limited in-depth assessment and documentation of the barriers to condom use among MSM in sub-Saharan Africa. In this paper, we examine the barriers to condom use among MSM in Uganda. Methods The data for this study were extracted from a larger qualitative study conducted among 85 self-identified adult (>18 years) MSM in 11 districts in Uganda between July and December 2013. Data on sexual behaviours and access and barriers to condom use were collected using semi-structured interviews. All interviews were audio-recorded and transcribed verbatim. This paper presents an analysis of data for 33 MSM who did not use condoms at last sex, with a focus on barriers to condom use. Analysis was conducted using the content analysis approach. Results Six major barriers to condom use were identified: Difficulties with using condoms, access challenges, lack of knowledge and misinformation about condom use, partner and relationship related issues, financial incentives and socio-economic vulnerability, and alcohol consumption. Conclusion The findings suggest that several reasons account for lack of condom use among high-risk MSM. The findings are valuable to inform interventions needed to increase condom use among MSM.

Why do GPs hesitate to refer diabetes patients to a self-management education program: a qualitative study

BackgroundSelf-management support is seen as a cornerstone of good diabetes care and many countries are currently engaged in initiatives to integrate self-management support in primary care. Concerning the organisation of these programs, evidence is growing that engagement of health care professionals, in particular of GPs, is critical for successful application. This paper reports on a study exploring why a substantial number of GPs was (initially) reluctant to refer patients to a self-management education program in Belgium.MethodsQualitative analysis of semi-structured face-to-face interviews with a purposive sample of 20 GPs who were not regular users of the service. The Greenhalgh diffusion of innovation framework was used as background and organising framework.ResultsSeveral barriers, linked to different components of the Greenhalgh model, emerged from the interview data. One of the most striking ones was the limited readiness for innovation among GPs. Feelings of fear of further fragmentation of diabetes care and frustration and insecurity regarding their own role in diabetes care prevented them from engaging in the innovation process. GPs needed time to be reassured that the program respects their role and has an added value to usual care. Once GPs considered referring patients, it was not clear enough which of their patients would benefit from the program. Some GPs expressed the need for training in motivational skills, so that they could better motivate their patients to participate. A practical but often mentioned barrier was the distance to the centre where the program was delivered. Further, uncertainty about continuity interfered with the uptake of the offer.ConclusionsThe study results contribute to a better understanding of the reasons why GPs hesitate to refer patients to a self-management education program. First of all, the role of GPs and other health care providers in diabetes care needs to be clarified before introducing new functions. Feelings of security and a basic trust of providers in the health system are a prerequisite for participation in care innovation. Moreover, some important lessons regarding the implementation of an education program in primary care have been learned from the study.

Improving Care And Research Electronic Data Trust Antwerp (iCAREdata): a research database of linked data on out-of-hours primary care

BackgroundPrimary out-of-hours care is developing throughout Europe. High-quality databases with linked data from primary health services can help to improve research and future health services.MethodsIn 2014, a central clinical research database infrastructure was established (iCAREdata: Improving Care And Research Electronic Data Trust Antwerp, www.icaredata.eu) for primary and interdisciplinary health care at the University of Antwerp, linking data from General Practice Cooperatives, Emergency Departments and Pharmacies during out-of-hours care. Medical data are pseudonymised using the services of a Trusted Third Party, which encodes private information about patients and physicians before data is sent to iCAREdata.ResultsiCAREdata provides many new research opportunities in the fields of clinical epidemiology, health care management and quality of care. A key aspect will be to ensure the quality of data registration by all health care providers.ConclusionsThis article describes the establishment of a research database and the possibilities of linking data from different primary out-of-hours care providers, with the potential to help to improve research and the quality of health care services.

Do informal caregivers for elderly in the community use support measures? A qualitative study in five European countries

BackgroundInformal caregivers are essential figures for maintaining frail elderly at home. Providing informal care can affect the informal caregivers’ physical and psychological health and labour market participation capabilities. They need support to prevent caregiver burden. A variety of existing support measures can help the caregiver care for the elderly at home, but with some limitations. The objective of this review was to explore the experiences of informal caregivers caring for elderly in the community with the use of supportive policy measures in Belgium and compare these to the experiences in other European countries.MethodsAn empirical qualitative case study research was conducted in five European countries (Belgium, The Netherlands, Luxembourg, France and Germany). Semi-structured interviews were conducted with informal caregivers and their dependent elderly. Interview data from the different cases were analysed. In particular data from Belgium was compared to data from the cases abroad.ResultsFormal services (e.g. home care) were reported to have the largest impact on allowing the caregiver to care for the dependent elderly at home. One of the key issues in Belgium is the lack of timely access to reliable information about formal and informal services in order to proactively support the informal caregiver. Compared to the other countries, informal caregivers in Belgium expressed more difficulties in accessing support measures and navigating through the health system. In the other countries information seemed to be given more timely when home care was provided via care packages.ConclusionTo support the informal caregiver, who is the key person to support the frail elderly, fragmentation of information regarding supportive policy measures is an important issue of concern.

Uncontrolled hypertension in Uganda : a comparative cross-sectional study

In a community survey, 4432 persons aged 15 years and older in two districts in Uganda were studied. Blood pressure was measured and predictors for subtypes of uncontrolled hypertension (HTN) were assessed using bivariate and multivariate logistic regression modeling. Prevalence of uncontrolled HTN was 20.2% and the subgroups of isolated systolic HTN (ISH), isolated diastolic HTN (IDH), and systolic‐diastolic HTN (SDH) were 7.2%, 4.2%, and 8.8%, respectively. No difference was observed between the sexes. For all HTN subtypes, middle (35–49 years) and older age (50+) groups had a higher prevalence compared with younger subjects (15–34 years) (all P<.001). IDH prevalence in older age was not higher compared with younger age (P=.417). After multivariate analysis, middle age predicted all subtypes of HTN and old age predicted ISH and SDH. Alcohol consumption predicted IDH and SDH. Uncontrolled HTN in this population increases in the order IDH, ISH, and SDH, with more than 1 in 5 having uncontrolled HTN.

Engaging GPs in insulin therapy initiation: a qualitative study evaluating a support program in the Belgian context

BackgroundA program supporting the initiation of insulin therapy in primary care was introduced in Belgium, as part of a larger quality improvement project on diabetes care. This paper reports on a study exploring factors influencing the engagement of general practitioners (GPs) in insulin therapy initiation (research question 1) and exploring factors relevant for future program development (research question 2).MethodsWe have used semi-structured interviews to answer the first research question: two focus group interviews with GPs who had at least one patient in the insulin initiation program and 20 one-to-one interviews with GPs who were not regular users of the overall support program in the region. To explore factors relevant for future program development, the data from the GPs were triangulated with data obtained from individual interviews with patients (n = 10), the diabetes nurse educator (DNE) and the specialist involved in the program, and data extracted from meeting reports evaluating the insulin initiation support program.ResultsWe found differences between GPs engaged and those not engaged in insulin initiation in attitude, subjective norm and perceived behavioural control regarding insulin initiation. In general the support program was evaluated in a positive way by users of the program. Some aspects need further consideration: job boundaries between the DNE and GPs, job boundaries between GPs and specialists, protocol adherence and limited case load.ConclusionThe study shows that the transition of insulin initiation from secondary care to the primary care setting is a challenge. Although a support program addressing known barriers to insulin initiation was provided, a substantial number of GPs were reluctant to engage in this aspect of care. Important issues for future program development are: an interdisciplinary approach to job clarification, a dynamic approach to the integration of expertise in primary care and feedback on protocol adherence.Trial registrationClinicalTrials.gov Identifier: NCT00824499

The perceptions and perspectives of patients and health care providers on chronic diseases management in rural South Africa: a qualitative study

BackgroundPreventive health care represents the future for health care delivery in South Africa to improve management of chronic diseases as this has been implemented for some time in several countries to tackle the increasing burden of chronic diseases. Individual person’s health is unique, as they move in and out of chronic and acute health care phases, there is need to integrate chronic and acute care constructs to improve continuity of care and maximize health and improve wellbeing. The aim of this study was to determine the perceptions and perspectives of chronic patients’ and nurses regarding chronic disease management in terms of barriers, facilitators and their experiences.MethodsTo meet our aim we used qualitative methods involving the collection of information by means of focus group discussions in Dikgale Health and Demographic Surveillance System (HDSS). All data was recorded, transcribed verbatim and analysed using data-driven thematic analysis.ResultsOur study showed that chronic disease patients have a first contact with health care professionals at the primary health care level in the study area. The main barriers mentioned by both the health care workers and chronic disease patients are lack of knowledge on chronic diseases, shortage of medication and shortage of nurses in the clinics which causes patients to wait for a long periods in a clinic. Health care workers are poorly trained on the management of chronic diseases. Lack of supervision by the district and provincial health managers together with poor dissemination of guidelines has been found to be a contributing factor to lack of knowledge in nurses among the clinics within the study area. Both patients and nurses mentioned the need to involve community health workers and traditional healers and integrate their services in order to early detect and manage chronic diseases in the community.ConclusionsNurses and chronic disease patients mentioned similar barriers to chronic disease management. Concerted action is needed to strengthen the delivery of medications at the clinics, improve the chronic disease knowledge for both nurses and patients by conducting in-service trainings or workshops, increase the involvement of community health workers and establish a link (through formal referral system) with traditional healers.