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Patients' and Healthcare Providers' Perspectives of Diabetes Open access Original research BMJ Open: first published as 10.1136/bmjopen-2019-032578 on 21 November 2019. Downloaded from Patients’ and healthcare providers’ perspectives of diabetes management in Cambodia: a qualitative study Ei Ei Khaing Nang ,1 Chhavarath Dary,2 Li Yang Hsu,1 Sokrath Sor,3 Vonthanak Saphonn,2 Konstantin Evdokimov1 To cite: Nang EEK, Dary C, ABSTRACT Strengths and limitations of this study Hsu LY, et al. Patients’ Objective This study aimed to explore the challenges and healthcare providers’ encountered by patients and healthcare providers and ► Views of patients and healthcare providers from perspectives of diabetes opportunities for improvement in managing diabetes management in Cambodia: a both public and private healthcare sectors allowed mellitus (DM) in a low- and middle- income country (LMIC) qualitative study. BMJ Open the triangulation of the diverse perspectives on dia- facing a rise in DM prevalence. 2019;9:e032578. doi:10.1136/ betes management. Design Qualitative cross- sectional study. bmjopen-2019-032578 ► Different levels of healthcare system including na- Setting Urban, semiurban, and rural areas in Cambodia. tional, provincial, and district level were covered. ► Prepublication history and Participants Thirty health service providers and fifty- nine ► The study was conducted in diverse geographical additional material for this adult DM patients. paper are available online. To regions of Cambodia including the regions near the Results Most of the 59 DM patients reported having view these files, please visit border and geographically isolated areas. developed DM complications when they first sought the journal online (http:// dx. doi. ► Most of the patient participants were recruited at treatment. The biggest challenges for the patients org/ 10. 1136/ bmjopen- 2019- the hospitals or through service providers; hence, were geographical barriers, diet control, and shortage 032578). diabetes patients who did not have access to these of medication supply. The healthcare staff expressed health services may have been missed. Received 26 June 2019 concerns about their limited knowledge and lack of Revised 07 October 2019 confidence to treat diabetes, limited availability of diabetes Accepted 21 October 2019 care services, inadequate laboratory services, shortage of staff, poor patients’ compliance, and insufficient Asia and western Pacific regions are at the medication supplies. Both healthcare staff and patients epicentre of the diabetes crisis. urged an expansion of diabetes services in Cambodia Cambodia located in the IDF Western Pacific http://bmjopen.bmj.com/ and prioritisation of diabetes care in a manner similar to communicable disease control programmes of the recent region is facing double burden of commu- past. nicable diseases and non- communicable Conclusions Currently, the Cambodian healthcare diseases (NCDs). The mortality due to isch- system has very limited capacity to provide quality care aemic heart disease and stroke increased for chronic diseases. As a consequence, many patients between 2000 and 2012 leading them into are either left untreated or have interrupted care due to top three causes of death in Cambodia.2 The several barriers including financial, geographical, and prevalence of impaired fasting glycaemia and lack of knowledge and skills. A more comprehensive and diabetes have dramatically increased from on September 24, 2021 by guest. Protected copyright. multipronged approach is urgently needed to improve 3 © Author(s) (or their 1.4% and 2.9% in 2010 to 8.9% and 9.6% DM care, which would require a collaborative effort from 4 employer(s)) 2019. Re- use in 2016. A modelling study based on STEPS government, external funding agencies, private sector, and permitted under CC BY-NC. No Survey 2010 data projected a 10% increase commercial re- use. See rights communities. and permissions. Published by of type 2 DM prevalence (80% increase in BMJ. absolute numbers) in the population older 5 1Epidemiology Domain, Saw INTRODUCTION than 35 years of age in Cambodia by 2028. Swee Hock School of Public Prevalence of diabetes mellitus (DM) Remarkably, the percentage of diabetes- Health, National University of is alarmingly increasing worldwide with related premature deaths and the prevalence Singapore, Singapore, Singapore approximately 425 million adults living with of undiagnosed DM in Cambodia is higher 2University of Health Sciences, and 352 million at risk of developing type 2 than in most other countries.1 It has been Phnom Penh, Cambodia 1 3Center for Livestock and diabetes in 2017. The International Diabetes reported that more than 50% of persons with 6 Agriculture Development Federation (IDF) projected 629 million DM in Cambodia were not treated while (CelAgrid), Phnom Penh, diabetics in 2045 and considered diabetes there was a high prevalence of complications Cambodia one of the largest global health emergencies such as renal failure in people with DM.7 The 1 Correspondence to in the 21st century. Seventy- nine per cent of socioeconomic burden of DM in Cambodia is 5 Dr Ei Ei Khaing Nang; adults with diabetes live in low- and middle- substantial with a clear upward trend but the nangeiei. khaing@ nih. gov income countries (LMICs), while south-east health system has been traditionally oriented Nang EEK, et al. BMJ Open 2019;9:e032578. doi:10.1136/bmjopen-2019-032578 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-032578 on 21 November 2019. Downloaded from Figure 1 A map depicting the four study sites in Cambodia. http://bmjopen.bmj.com/ towards communicable diseases control and may not be Eligibility criteria ready to cope with the rising burden of NCDs.8 Healthcare providers were eligible to participate in In order to formulate effective policies and interven- in- depth interviews (IDIs) if they had at least 1 year tions, it is imperative to understand the challenges and of experience in providing care for diabetes/chronic opportunities of managing DM in the local population. diseases. Any individual aged 21 years and above, diag- However, these have not been addressed in Cambodia nosed with DM with or without complications and/ on September 24, 2021 by guest. Protected copyright. in depth yet. Here we report patients’ and health service or with any duration of the disease since diagnosis was providers’ perspectives of managing DM in Cambodia. considered an eligible patient for focus group discussions (FGDs). Data collection MATERIALS AND METHODS To achieve maximum variation, we interviewed 30 health- Research design care providers at the national, provincial, and district This qualitative cross-sectional study addressed the level and peer educators of a local non-governmental perspectives of patients and healthcare providers in organisation (NGO) providing DM service. managing diabetes in Cambodia. Healthcare staff helped the research team in recruiting DM patients for FGDs as follows. The study was presented Sampling to the healthcare staff of the participating institutions, Four provinces of Cambodia: Phnom Penh (capital of the peer educators and community leaders, whereupon they country), Siem Reap and Banteay Meanchey (north-west disseminated the information about the study among of the country), and Mondulkiri (east of the country) their patients or communities. Individuals who expressed (figure 1) were selected based on the level of urbanicity, interest to participate attended information sessions geographic location, and feasibility. organised by the study team and later joined focus group 2 Nang EEK, et al. BMJ Open 2019;9:e032578. doi:10.1136/bmjopen-2019-032578 Open access BMJ Open: first published as 10.1136/bmjopen-2019-032578 on 21 November 2019. Downloaded from discussions. In total, 59 eligible adults attended seven Table 1 Characteristics of in- depth interview participants FGDs in groups of 5–10 patients. Semistructured interview guides were used to facili- Age (median, min–max) 35 (24–60) tate IDIs and FGDs (online supplementary files 1 and Gender (N, %) 2). The interviews were conducted in Khmer by trained Male 21 (70.00) researchers. Female 9 (30.00) Data analysis Education (N, %) Bilingual research staff transcribed all interviews verbatim Primary school 2 (6.67) and translated them into English. We used both induc- Secondary school 2 (6.67) tive and deductive approaches when analysing the data. High school/professional technical training 6 (20.00) Inductive analysis was used in the early stage to explore University/post- graduate 20 (66.67) the ideas and meanings contained in the raw data and to identify concepts, patterns and themes. Similar codes Profession (N, %) were collated to form initial themes. Once patterns, Doctor 14 (46.67) themes and subthemes were established by open coding, Nurse 12 (40.00) deductive content analysis was used to validate these in an Peer educator 4 (13.33) iterative process. We reported the results in patient-based, Year of work in DM care (N, %) provider- based and health-system- based issues. QSR NVivo V.11 for Windows was used to manage the data. 0 to <1 year 4 (16.67) Figure 1 illustrating the study sites was produced with 1–5 years 11 (36.67) QGIS 2.14.9-Essen. Administrative areas level 0 and 1 for 5–10 years 9 (30.00) Cambodia, Thailand, Laos and Vietnam (solid lines) were >10 years 5 (16.67) downloaded from the Database of Global Administrative Number of patients treated in the past 6 Areas. The roads data (dotted lines) were obtained from months (N, %) the OpenStreetMap Data Extracts. 0 to
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