Team-Based Approach in the Management of Diabetes at Primary Health Care Level in Muscat, Oman Challenges and Opportunities

Team-based Approach in the Management of Diabetes at Primary Health Care Level in Muscat, Oman Challenges and Opportunities

Kamila Al Alawi

Team-based Approach in the Management of Diabetes at Primary

Health Care Level in Muscat, Oman:

Challenges and Opportunities

Kamila Al Alawi

Department of Epidemiology and Global Health

Umeå University Umeå 2019

This work is protected by the Swedish Copyright Legislation (Act 1960:729) Dissertation for PhD ISBN: 978-91-7855-042-5 ISSN: 0346-6612 New Series No. 2025 Cover design by: Reem Al-Sabti, Ali Al-Sabti, Noor Al-Sabti and Marwa Al-Sabti Electronic version available at: http://umu.diva-portal.org/ Printed by: Cityprint i Norr AB Umeå University, Sweden 2019

“And say, oh my Lord increase my knowledge” Surah Taha - verse 114

Table of Contents

List of Tables ...... vii List of Figures ...... ix Abbreviations ...... xi Abstract ...... xiii Summary of the PhD Project in Arabic Language ...... xv Original Papers ...... xvii Prologue ...... xix

Introduction ...... 1 Type 2 diabetes and its global spread ...... 1 Type 2 diabetes in the Middle East ...... 1 Chronic care model ...... 2 Team-based approach in diabetes management ...... 3 Oman and Type 2 diabetes management situation ...... 7 Oman’s geography and demography ...... 7 Omani people’s lifestyle ...... 9 Type 2 diabetes epidemic ...... 10 The health care system ...... 10 The team-based approach in diabetes management clinics in the public primary health care system...... 11 Knowledge gap and contribution of this PhD project ...... 12 Main and specific aims of the studies ...... 13 Main aim ...... 13 Specific aims ...... 13

Materials and Methods ...... 15 General project design ...... 15 Project setting and sample selection ...... 18 Studies’ Methods ...... 19 Cross-sectional survey (Study 1) ...... 19 Qualitative non-participant observations of diabetes consultations (Study 2) ...... 22 Qualitative interviews with health care providers (Studies 2 and 3) ...... 23 Qualitative interviews with type 2 diabetic patients (Study 4) ...... 24 Studies’ data analysis ...... 25 Statistical analysis (Study 1) ...... 25 Descriptive summaries and qualitative content analysis (Study 2) ...... 25 Qualitative thematic analysis (Studies 3 and 4) ...... 26 Ethical considerations ...... 27

Results ...... 29 Competencies, values, skills and resources related to the team–based approach: PHCPs’ perceptions (Study 1) ...... 29 PHCPs’ self-perceived competencies ...... 30 PHCPs’ self-perceived values ...... 30 PHCPs’ self-perceived team-related skills ...... 30 PHCPs’ self-perceived support/resources ...... 31 Challenges and opportunities for improvement in diabetes management: PHCPs’ perceptions (Study 2) ...... 31 Team-based approach within different models of service delivery at diabetes management clinics ...... 31 Challenges exposed during the interviews ...... 32 Task-sharing mechanism and its complete implementation: PHCPs’ perception (Study 3) ...... 34 The current diabetes service and nurse-led clinics: Type 2 diabetes patients’ opinions...... 36 Dissemination of results ...... 37

Discussion ...... 39 The current situation (Studies 1 and 2) ...... 39 Understanding of the team kinetics (Studies 1, 2, and 3) ...... 40 The missing link of the team (Studies 1, 2, and 3) ...... 41 Type 2 diabetes patients and nurse-led clinics (Studies 3 and 4) ...... 42 Methodological considerations ...... 43

Conclusions and Recommendations ...... 47 Conclusions and contribution of this thesis ...... 47 Recommendations for future research ...... 47

Acknowledgments ...... 49 References ...... 53 Appendix ...... 61

List of Tables

Table 1. Thesis at a glance Table 2. Provinces of Muscat Governorate and their populations Table 3. Participants in the qualitative studies Table 4. The four themes, including the 31 categorized items Table 5. Example of the coding process Table 6. Task-sharing preferability, positive outcomes, worries and requirements

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viii

List of Figures

Figure 1. The chronic care model Figure 2. A continuum of team health care practice models Figure 3. Key contributors to a successful interdisciplinary team in diabetes care Figure 4. Map of Oman Figure 5. Map of Muscat Governorate Figure 6. PHCPs’ tasks and roles Figure 7. Interview in progress with PHCP Figure 8. Poster presentation at 20th European Congress of Endocrinology Figure 9. Published scientific papers (1 and 2)

Abbreviations

CCM Chronic Care Model GCCs Gulf Council Countries GDP Gross Domestic Product HRH Human Resources for Health MOH Ministry of Health NCDs Non-Communicable Diseases PHCC Primary Health Care Centre PHCP Primary Health Care Provider WHO World Health Organization

xii

Abstract

Introduction: The growth of type 2 diabetes is considered an alarming epidemic in Oman. The efficient team-based approach to diabetes management in primary health care is an essential component for providing ideal diabetic care. This thesis aimed to explore the current situation related to team-based management of type 2 diabetes in public Primary Health Care Centres (PHCCs) under the Ministry of Health (MOH) in Oman, including the various challenges associated with diabetes management and the most preferable Human Resources for Health (HRH) management mechanism, and to examine how this could be optimized from provider and patient perspectives.

Materials and methods: The entire project was conducted in Muscat Governorate and was based on one quantitative and three qualitative studies. In the quantitative study, 26 public PHCCs were approached through cross- sectional study. The core diabetes management team recommended by the MOH for PHCCs in Oman was explored in terms of their competencies, values, skills, and resources related to the team-based approach to diabetes management. For the qualitative studies, five public purposely-selected PHCCs were approached. The diabetes consultations conducted by the core members and other supportive members involved in diabetes management were observed and later the Primary Health Care Providers (PHCPs) were interviewed. The different approaches explored challenges related to diabetes management and the most preferable HRH mechanism by PHCPs. Seven type 2 diabetes patients with different gender, employment status, and education were consequently interviewed to explore their perceptions towards the current diabetes management service and their opinions towards nurse-led clinics.

Results: The survey provided significant and diverse perceptions of PHCPs towards their competencies, values, skills, and resources related to diabetes management. Physicians considered themselves to have better competencies than nurses and dieticians. Physicians also scored higher on team-related skills and values compared with health educators. In terms of team-related skills, the difference between physicians and nurses was statistically significant and showed that physicians perceived themselves to have better skills than nurses. Confusion about the leadership concept among PHCPs with a lack of pharmacological, technical, and human resources was also reported. The observations and interviews with PHCPs disclosed three different models of service delivery at diabetes management clinics. The challenges explored involved PHCCs’ infrastructure, nurses’ knowledge, skills, and non-availability of technical and pharmaceutical support. Other challenges that evolved into the community were cultural beliefs, traditions, health awareness, and public

xiii transportation. Complete implementation of task-sharing mechanisms within the team-based approach was selected by all PHCPs as the most preferable HRH mechanism. The selection was discussed in the context of positive outcomes, worries, and future requirements. The physicians stated that nurses’ weak contribution to the team within the selected mechanism could be the most significant aspect. Other members supported the task-sharing mechanism between physicians and nurses. However, type 2 diabetes patients’ non- acceptance of a service provided by the nurses created worries for the nurses. The interviews with type 2 diabetes patients disclosed positive perceptions towards the current diabetes management visits; however, opinions towards nurse-led clinics varied among the patients.

Conclusions and recommendations: The team-based approach at diabetes management clinics in public PHCCs in Oman requires thoughtful attention. Diverse presence of the team members can form challenges during service delivery. Clear roles for team members must be outlined through a solid HRH management mechanism in the context of a sharp leadership concept. Nurse- led clinics are an important concept within the team; however, their implementation requires further investigation. The concept must involve clear understandings of independence and interdependence by the team members, who must be educated to provide a strong gain for team-based service delivery.

Keywords: Challenges, Health care providers, Oman, Perceptions, Primary health care, Team-based approach, Type 2 diabetes, Nurse-led clinics.

xiv

Summary of the PhD Project in Arabic Language

ﻟﻘﺪ ﺍﻭﻟﺖ ﺍﻟﺤﻜﻮﻣﻪ ﺍﻟﺮﺷﻴﺪﻩ ﺑﺴﻠﻄﻨﻪ ﻋﻤﺎﻥ ﻭﺑﻮﺟﻪ ﺍﻟﺨﺼﻮﺹ ﻭﺯﺍﺭﻩ ﺍﻟﺼﺤﻪ ﺍﻫﺘﻤﺎﻣﺎ ﻓﺎﺋﻘﺎ ﺑﺎﻟﻌﻨﺎﻳﻪ ﺍﻟﺼﺤﻴﻪ ﺍﻻﻭﻟﻴﻪ ﻭﺑﺎﻷﺧﺺ ﻋﻼﺝ ﺍﻻﻣﺮﺍﺽ ﺍﻟﻤﻨﺘﺸﺮﻩ ﺑﺸﻜﻞ ﺷﺎﺋﻊ ﻓﻲ ﺍﻟﺴﻠﻄﻨﻪ ﻭﻣﻦ ﺿﻤﻨﻬﺎ ﺍﻫﺘﻤﺎﻡ ﻭﺯﺍﺭﻩ ﺍﻟﺼﺤﻪ ﺑﻌﻼﺝ ﻣﺮﺽ ﺍﻟﺴﻜﺮﻱ ﻭﺫﻟﻚ ﻟﻤﺎ ﻟﻬﺬﺍ ﺍﻟﻤﺮﺽ ﻣﻦ ﻣﺘﻄﻠﺒﺎﺕ ﺍﻟﺘﻲ ﻳﺠﺐ ﺗﻮﻓﻴﺮﻫﺎ ﻟﻠﻮﺻﻮﻝ ﺍﻟﻰ ﺍﻋﻠﻰ ﺩﺭﺟﺎﺕ ﺍﻟﺨﺪﻣﻪ ﻭﺍﻟﺘﻤﻴﺰ ﺍﻟﺼﺤﻲ.

ﻭﻳﻌﺘﺒﺮ ﻣﺮﺽ ﺍﻟﺴﻜﺮﻱ ﻭﺑﺎﻷﺧﺺ ﺍﻟﻨﻮﻉ ﺍﻟﺜﺎﻧﻲ ﻣﻦ ﺍﻻﻣﺮﺍﺽ ﺍﻟﺸﺎﺋﻌﻪ ﻓﻲ ﺳﻠﻄﻨﻪ ﻋﻤﺎﻥ ﻭﺫﻟﻚ ﻭﻓﻖ ﺍﻻﺣﺼﺎﺋﻴﺎﺕ ﺍﻟﻮﻁﻨﻴﻪ ﺍﻟﻤﻌﺘﻤﺪﻩ ﻓﻲ ﺍﻟﺴﻠﻄﻨﻪ، ﻭﻟﻬﺬﺍ ﻓﺎﻥ ﺍﻟﺤﻜﻮﻣﻪ ﺍﻟﺮﺷﻴﺪﻩ ﻣﺘﻤﺜﻠﻪ ﻓﻲ ﻭﺯﺍﺭﻩ ﺍﻟﺼﺤﻪ ﻧﻬﺠﺖ ﻋﺪﻩ ﻁﺮﻕ ﻭﻋﺪﻩ ﻭﺳﺎﺋﻞ ﻟﻌﻼﺝ ﻣﺮﺽ ﺍﻟﺴﻜﺮﻱ ﻭﻣﻦ ﺿﻤﻨﻬﺎ ﺗﻮﻓﻴﺮ ﻓﻲ ﺍﻟﻤﺮﺍﻛﺰ ﺍﻟﺼﺤﻴﻪ ﺍﻻﻭﻟﻴﻪ ﻓﺮﻳﻘﺎ ﺻﺤﻴﺎ ﻣﺘﻜﺎﻣﻼ ﻗﺎﺩﺭﺍ ﻋﻠﻰ ﺗﻮﺻﻴﻞ ﺍﻟﻌﻼﺝ ﺍﻟﻰ ﺍﻟﻤﺮﺿﻰ ﺑﺎﻟﻄﺮﻕ ﺍﻟﻤﺜﻠﻰ.

ﻭﻣﻤﺎ ﻻ ﺷﻚ ﻓﻴﻪ ﻓﺎﻥ ﻫﺬﺍ ﺍﻟﻔﺮﻳﻖ ﻻ ﺑﺪ ﺍﻥ ﻳﺒﺬﻝ ﻗﺼﺎﺭﻯ ﺟﻬﺪﻩ ﻭﻳﺘﻔﺎﻧﻰ ﻓﻲ ﻋﻤﻠﻪ ﻟﺨﺪﻣﻪ ﺍﺑﻨﺎء ﺍﻟﻮﻁﻦ ﻭﺍﻟﻤﻘﻴﻤﻴﻦ ﻓﻴﻪ، ﺍﻻ ﺍﻥ ﺍﻟﺘﻄﻠﻌﺎﺕ ﻭﺍﻟﺮﺅﻳﺎ ﺩﺍﺋﻤﺎ ﻁﻤﻮﺣﻪ، ﻟﺬﻟﻚ ﻳﺄﺗﻲ ﺍﻟﺴﻌﻲ ﻟﺒﻨﺎء ﻋﻴﺎﺩﺍﺕ ﻣﺮﺽ ﺍﻟﺴﻜﺮﻱ ﻓﻲ ﺍﻟﻤﺮﺍﻛﺰ ﺍﻟﺼﺤﻴﻪ ﺍﻻﻭﻟﻴﻪ ﻓﻲ ﻫﺬﺍ ﺍﻟﻮﻁﻦ ﻭﻓﻖ ﺩﻗﻪ ﺗﺤﺘﻮﻳﻬﺎ ﺍﻟﺠﻮﺩﻩ ﻭﺍﻻﺗﻘﺎﻥ، ﻭﺑﻨﺎء ﻋﻠﻰ ﻣﺎ ﺗﻘﺘﻀﻴﻪ ﺍﻟﻤﺼﻠﺤﻪ ﺍﻟﺼﺤﻴﻪ ﻟﻠﻤﻮﺍﻁﻨﻴﻦ ﻭﻟﻠﻤﻘﻴﻤﻴﻦ ، ﻭﺗﻤﺎﺷﻴﺎ ﻣﻊ ﺍﻻﺭﺷﺎﺩﺍﺕ ﺍﻟﺼﺤﻴﻪ ﺍﻟﻌﺎﻟﻤﻴﻪ ﻭﺫﻟﻚ ﻣﻦ ﺧﻼﻝ ﺍﻟﺠﻬﺪ ﺍﻟﻜﺒﻴﺮ ﺍﻟﺬﻱ ﺗﺘﺒﻨﺎﻩ ﻭﺯﺍﺭﻩ ﺍﻟﺼﺤﻪ ﺍﻟﻤﻮﻗﺮﻩ ﻓﻲ ﻋﻼﺝ ﻣﺮﺽ ﺍﻟﺴﻜﺮﻱ، ﺗﻢ ﺍﻟﻨﻈﺮ ﻋﻦ ﻛﺜﺐ ﺍﻟﻰ ﻫﺬﻩ ﺍﻟﻔﺮﻕ ﺍﻟﺼﺤﻴﻪ ﺍﻟﻤﺘﻮﻓﺮﻩ ﻓﻲ ﺍﻟﻤﺮﺍﻛﺰ ﺍﻟﺼﺤﻴﻪ ﺍﻻﻭﻟﻴﻪ ﻭﻣﻌﺮﻓﻪ ﻣﺎ ﺇﺫﺍ ﻛﺎﻥ ﻫﻨﺎﻙ ﺧﻠﻞ ﻣﻌﻴﻦ ﻓﻲ ﺗﻮﺻﻴﻞ ﺍﻟﻌﻼﺝ ﻟﻠﻤﺮﺿﻰ ﺍﻡ ﻻ.

ﻓﺘﻢ ﺍﻟﺘﺨﻄﻴﻂ ﻟﻬﺬﺍ ﺍﻟﻤﺸﺮﻭﻉ ﻣﻦ ﺧﻼﻝ ﻋﺪﻩ ﺍﺳﺌﻠﻪ: ﻣﻦ ﻫﻢ ﺍﻋﻀﺎء ﺍﻟﻔﺮﻳﻖ ﻓﻲ ﺍﻟﻮﻗﺖ ﺍﻟﺤﺎﻟﻲ ﻓﻲ ﻋﻴﺎﺩﺍﺕ ﻣﺮﺽ ﺍﻟﺴﻜﺮﻱ؟ ﻭﻫﻞ ﺑﺎﻹﻣﻜﺎﻥ ﺍﻻﻋﺘﻤﺎﺩ ﻋﻠﻴﻬﻢ ﻟﺘﻮﺻﻴﻞ ﺍﻟﻌﻼﺝ ﺍﻟﻤﻨﺎﺳﺐ ﻟﻠﻤﺮﺿﻰ؟ ﻭﻣﺎ ﻫﻲ ﺍﻻﺳﺘﺮﺍﺗﻴﺠﻴﺎﺕ ﻭﺍﻟﺨﻄﻂ ﺍﻟﻤﺘﺒﻌﻪ ﻭﺍﻟﺘﻲ ﻳﻤﺎﺭﺳﻬﺎ ﺍﻻﻋﻀﺎء ﻓﻲ ﺍﻟﻮﻗﺖ ﺍﻟﺤﺎﻟﻲ؟ ﻭﻣﺎﻫﻲ ﺍﻟﺮﺅﻯ ﺍﻟﻤﺴﺘﻘﺒﻠﻴﻪ ﻟﻠﻔﺮﻳﻖ ﻭﻫﻞ ﺑﺎﻹﻣﻜﺎﻥ ﺗﻄﻮﻳﺮ ﺍﻟﻔﺮﻳﻖ ﻭﺍﺳﻨﺎﺩ ﻣﻬﺎﻡ ﺟﺪﻳﺪﻩ ﻷﻋﻀﺎء ﺍﻟﻔﺮﻳﻖ ﻭﻣﺨﺘﻠﻔﻪ ﻋﻦ ﺍﻟﺘﻲ ﻳﻘﻮﻣﻮﻥ ﺑﻬﺎ ﺣﺎﻟﻴﺎ ﻭﻫﻞ ﺑﺎﻹﻣﻜﺎﻥ ﺗﻄﺒﻴﻖ ﺍﻟﺘﻐﻴﻴﺮﺍﺕ ﺍﻟﻤﻘﺘﺮﺣﻪ ﻭﺗﻨﻔﻴﺬﻫﺎ ﻓﻲ ﺍﻟﻤﺴﺘﻘﺒﻞ؟

ﻛﻞ ﻫﺬﻩ ﺍﻻﺳﺌﻠﻪ ﻛﺎﻧﺖ ﻣﺤﻮﺭﺍ ﻟﻬﺬﺍ ﺍﻟﻤﺸﺮﻭﻉ، ﻭﻟﻢ ﻳﻜﺘﻔﻲ ﺍﻟﻤﺸﺮﻭﻉ ﺑﻬﺬﻩ ﺍﻻﺳﺌﻠﻪ ﻷﻋﻀﺎء ﺍﻟﻔﺮﻳﻖ ﺍﻟﺼﺤﻲ ﻓﺤﺴﺐ ﺑﻞ ﻛﺎﻥ ﻟﻠﻤﺮﺿﻰ ﺫﺍﺗﻬﻢ ﺩﻭﺭﺍ ﻣﺤﻮﺭﻳﺎ ﻻﻓﺘﺎ ﻟﻠﻨﻈﺮ ﻭﺫﻟﻚ ﻣﻦ ﺧﻼﻝ ﻣﻘﺎﺑﻠﺘﻬﻢ ﻭﺳﺆﺍﻟﻬﻢ ﻋﻦ ﻣﺪﻯ ﺭﺿﺎﻫﻢ ﻋﻦ ﺍﻟﺰﻳﺎﺭﺍﺕ ﻟﻌﻴﺎﺩﺍﺕ ﻣﺮﺽ ﺍﻟﺴﻜﺮﻱ ﻭﺇﺫﺍ ﻛﺎﻧﺖ ﻟﺪﻳﻬﻢ ﺍﻟﺮﻏﺒﻪ ﻣﺴﺘﻘﺒﻼ ﻭﺍﻟﻤﻮﺍﻓﻘﻪ ﻓﻲ ﻣﻘﺎﺑﻠﻪ ﻣﻮﻅﻔﻲ ﺍﻟﺘﻤﺮﻳﺾ ﺧﻼﻝ ﺯﻳﺎﺭﺗﻬﻢ ﻟﻠﻌﻴﺎﺩﻩ ﺩﻭﻥ ﺍﻟﻠﺠﻮء ﺍﻟﻰ ﺯﻳﺎﺭﺓ ﺍﻟﻄﺒﻴﺐ ﺍﻻ ﻟﻠﻀﺮﻭﺭﻩ ﺍﻟﻘﺼﻮﻯ.

ﻭﺍﻻﻣﺮ ﺍﻟﻼﻓﺖ ﻟﻠﻨﻈﺮ ﻭﺍﻟﺬﻱ ﺑﺤﺎﺟﻪ ﺍﻟﻰ ﺗﺴﻠﻴﻂ ﺍﻟﻀﻮء ﻋﻠﻴﻪ ﻫﻲ ﺍﻟﻨﺘﺎﺋﺞ ﺍﻟﺘﻲ ﺧﺮﺟﺖ ﺑﻬﺎ ﻫﺬﻩ ﺍﻟﺪﺭﺍﺳﻪ ﻭﺗﺘﻤﺜﻞ ﻓﻲ ﻭﺟﻮﺩ ﺧﻠﻞ ﻭﺿﻌﻒ ﻣﻠﺤﻮﻅ ﻓﻲ ﺍﻏﻠﺐ ﻣﻮﻅﻔﻲ ﺍﻟﺘﻤﺮﻳﺾ ﻭﺑﺎﻷﺧﺺ ﻓﻲ ﺍﻟﻜﻔﺎءﻩ ﺍﻟﻤﻌﺮﻓﻴﻪ ﻭﺍﻟﺨﻠﻔﻴﻪ ﺍﻟﻤﻠﻤﻪ ﻟﻤﺮﺽ ﺍﻟﺴﻜﺮﻱ.

ﻭﻣﻦ ﺍﻟﺠﺪﻳﺮ ﺑﺎﻟﺬﻛﺮ ﺍﻥ ﺍﻻﻁﺒﺎء ﺑﻌﺪ ﻣﻌﺮﻓﺘﻬﻢ ﺑﻨﺘﺎﺋﺞ ﻫﺬﻩ ﺍﻟﺪﺭﺍﺳﻪ ﺃﻋﺮﺑﻮﺍ ﻋﻦ ﺭﻏﺒﺘﻬﻢ ﻟﻠﻤﺴﺎﻋﺪﻩ ﻭﺫﻟﻚ ﻓﻲ ﺿﻮء ﺗﻌﺰﻳﺰ ﻣﻜﺎﻧﻪ ﺍﻟﺘﻤﺮﻳﺾ ﻭﺍﻟﺴﻤﺎﺡ ﻟﻤﺴﺆﻭﻟﻲ ﻭﺯﺍﺭﻩ ﺍﻟﺼﺤﻪ ﻓﻲ ﺗﻄﻮﻳﺮ ﺍﺩﻭﺍﺭﻫﻢ.

ﺍﻣﺎ ﺑﺎﻟﻨﺴﺒﻪ ﻟﻠﻨﺘﺎﺋﺞ ﺍﻟﺘﻲ ﺗﻢ ﺍﻟﻮﺻﻮﻝ ﺍﻟﻴﻬﺎ ﺇﺛﺮ ﺩﺭﺍﺳﻪ ﺍﺭﺍء ﺍﻟﻤﺮﺿﻰ ﻓﻲ ﺗﻄﻮﻳﺮ ﻋﻴﺎﺩﺍﺕ ﺍﻟﺴﻜﺮﻱ ﻭﺭﻏﺒﺘﻬﻢ ﻓﻲ ﻣﻘﺎﺑﻠﻪ ﻣﻮﻅﻔﻲ ﺍﻟﺘﻤﺮﻳﺾ ﺩﻭﻥ ﺍﻟﻠﺠﻮء ﺍﻟﻲ ﺯﻳﺎﺭﺓ ﺍﻟﻄﺒﻴﺐ ﺍﻻ ﻟﻠﻀﺮﻭﺭﻩ ﻓﻘﺪ ﺍﻧﻘﺴﻢ ﺍﻟﻤﺮﺿﻰ ﻓﻲ ﺁﺭﺍﺋﻬﻢ ﺍﻟﻰ ﺛﻼﺙ ﻣﺠﻤﻮﻋﺎﺕ: ﻣﺠﻤﻮﻋﻪ ﻣﻮﺍﻓﻘﻪ ﺗﻤﺎﻣﺎ، ﻣﺠﻤﻮﻋﻪ ﻣﻮﺍﻓﻘﻪ ﻭﻟﻜﻦ ﺑﺸﺮﻭﻁ ﻭﻣﺠﻤﻮﻋﻪ ﺭﺍﻓﻀﻪ ﺗﻤﺎﻣﺎ ﻟﺘﻠﻘﻲ ﺍﻟﻌﻼﺝ ﻣﻦ ﻣﻮﻅﻔﻲ ﺍﻟﺘﻤﺮﻳﺾ.

ﺍﻟﺘﺤﺪﻳﺎﺕ ﺑﺎﺗﺖ ﻭﺍﺿﺤﺔ ﻭﻣﺸﺎﺭﻳﻊ ﻣﺴﺘﻘﺒﻠﻴﻪ ﻟﺒﺤﺚ ﺍﻟﻘﻀﺎﻳﺎ ﺍﻟﻤﺘﻌﻠﻘﻪ ﺑﻌﻼﺝ ﻣﺮﺽ ﺍﻟﺴﻜﺮﻱ ﻓﻲ ﺍﻟﺴﻠﻄﻨﻪ ﺍﺻﺒﺤﺖ ﻣﻬﻤﻪ ﻭﻻ ﺑﺪ ﺍﻥ ﻳﻨﻈﺮ ﻟﻬﺎ ﺟﺪﻳﺎ ﻭﺗﻜﻮﻥ ﻣﻦ ﺍﻻﺳﺎﺳﻴﺎﺕ ﺍﻟﻤﺪﺭﺟﻪ ﻓﻲ ﺍﻟﺨﻄﻂ ﺍﻟﻤﺴﺘﻘﺒﻠﻴﻪ ﻟﻮﺯﺍﺭﻩ ﺍﻟﺼﺤﻪ، ﺍﻳﻀﺎ ﺭﻓﻊ ﻣﺴﺘﻮﻯ ﺍﻟﺘﻤﺮﻳﺾ ﻭﺗﺸﺠﻴﻌﻬﻢ ﻟﻠﺨﻮﺽ ﻓﻲ ﻣﺠﺎﻝ ﺍﻟﺴﻜﺮﻱ ﺍﻣﺮ ﻣﻬﻢ ﻟﻠﻐﺎﻳﻪ ﻭﻻ ﺑﺪ ﺍﻟﻨﻈﺮ ﺍﻟﻴﻪ ﺑﻌﻴﻦ ﺍﻟﺨﺒﺮﻩ ﻭﺍﻟﻜﻔﺎءﻩ.

ﺗﻄﻮﻳﺮ ﻋﻴﺎﺩﺍﺕ ﻣﺮﺽ ﺍﻟﺴﻜﺮﻱ ﻭﺫﻟﻚ ﺗﺠﺎﻭﺑﺎ ﻣﻊ ﺍﻟﺘﻮﺻﻴﺎﺕ ﺍﻟﻌﺎﻟﻤﻴﻪ ﺍﻣﺮ ﻻ ﺑﺪ ﻣﻨﻪ ﻭﻟﻜﻦ ﻳﺤﺘﺎﺝ ﺍﻟﻰ ﺩﺭﺍﺳﻪ ﺍﻟﺨﻄﻮﺍﺕ ﺟﻴﺪﺍ ﻗﺒﻞ ﺗﻄﺒﻴﻘﻬﺎ ﻭﺍﺩﺭﺍﺝ ﺍﻟﻤﻬﺘﻤﻴﻦ ﺑﻤﺮﺽ ﺍﻟﺴﻜﺮﻱ ﺑﺎﻟﺴﻠﻄﻨﻪ ﺍﻟﻰ ﺍﻟﻌﻤﻞ ﻹﻳﺠﺎﺩ ﻁﺮﻳﻘﻪ ﻣﺜﻠﻰ ﻟﺘﻨﻔﻴﺬ ﻫﺬﻩ ﺍﻟﺨﻄﻮﺍﺕ.

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Original Papers

The PhD project is based on the following papers, referred to as studies 1- 4:

1. Al-Alawi K, Johansson H, Al Mandhari A, Norberg M. Are the resources adoptive for conducting team-based diabetes management clinics? An explorative study at primary health care centers in Muscat, Oman. Primary Health Care Research & Development. 2018 May 8:1-28. doi: 10.1017/S1463423618000282.

2. Al-Alawi K, Al Mandhari A, Johansson H. Care providers’ perception towards challenges and opportunities for service improvement at diabetes management clinics in public primary health care in Muscat, Oman: A qualitative study. BMC, Health Service Research. 2019 January 8.doi.org/10.1186/s12913-019-3866-y.

3. Al-Alawi K, Johansson H. The question is not what we want; the question is, are we ready? A qualitative study exploring providers’ perceptions towards different human resources for health management mechanisms at diabetes management clinics in primary health care centres in Muscat, Oman. (Manuscript)

4. Al-Alawi K, Johansson H. Perceptions of type 2 diabetes patients towards diabetes management visits at public primary health care centres with diverse opinions towards nurse-led clinics in Muscat, Oman: A pilot qualitative study. (Manuscript)

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Prologue

After my MSc degree in Medical Education from Cardiff University and my return home, I still had a deep will to continue my studies to achieve a PhD degree. The opportunity came when I was awarded a PhD scholarship by the Ministry of Health (MOH), Oman. This reward came along with an invitation to meet His Excellency the Director of Planning to discuss different challenges in the ministry related to health care, health systems, and health service provision. The discussion was guided by the possibility of incorporating some of these challenges into my PhD project. Among the different challenges mentioned was a shortage of physicians at Primary Health Care Centres (PHCCs) under the MOH, which was the most thought-provoking challenge. This motivated me and gave me the idea to include it in my PhD and explore it further.

The interest in exploring the challenge was strongly linked to my background as a physician and my strong personal interest towards teamwork and team-based approach. Additionally, the rapid increase in the prevalence of type 2 diabetes in the country, to epidemic proportions, gave me the opportunity to implement my project at diabetes management clinics in PHCCs, where a team-based service is provided with an anticipated shortage of physicians.

Therefore, my background as a physician with a proposed challenge of the shortage of physicians and my interest in the team-based approach within the diabetes epidemic context provided the three pillars needed for the project to commence.

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INTRODUCTION

Introduction

This chapter opens with close documentation of the type 2 diabetes epidemic and an exploration of the team-based approach to management, both of which could lead to reconceptualization of the teamwork approach in the Omani primary health care setting.

Type 2 diabetes and its global spread Diabetes is a serious global health problem with alarming outcomes (1). In terms of worldwide burden, the World Health Organization (WHO) estimated that around 194 million people in the world had diabetes in the year 2003. The future estimation is not optimistic, as this figure may more than double by the year 2025 (1). Many WHO reports confirm that diabetes is now one of the most common Non-Communicable Diseases (NCDs) globally. It is the fourth or fifth leading cause of death in most high-income countries, and there is substantial evidence that it is an epidemic in many middle- and low-income countries and newly industrialized nations (1).

Type 2 diabetes comprises about 85%‒95% of diabetes cases in high-income countries, and accounts for an even higher percentage in middle- and low- income countries. These figures may significantly misjudge the magnitude of the problem, since up to 50% of the population with diabetes are thought to remain undiagnosed and therefore untreated (2).

Type 2 diabetes is associated with rapid cultural and social changes, increasing urbanization, dietary changes, reduced physical activity, and other unhealthy lifestyle and behavioural patterns (1). A WHO report has shown that type 2 diabetes is a direct consequence of obesity, a fatty diet, and inactivity (3). Therefore, based on the available evidence regarding diet and lifestyle in the prevention of type 2 diabetes, normal weight status should be maintained, regular physical activity should be continued throughout childhood and adulthood, and saturated fat intake should be restricted (4). The literature has also shown that being overweight in early and middle age predicts and increases the risk of type 2 diabetes (5, 6).

Type 2 diabetes in the Middle East The explosion in the number of diabetes cases in the Middle East region, specifically in the Gulf Council Countries (GCCs), is mainly due to type 2 diabetes. An estimated 19.2 million people, or 7% of the adult population, have type 2 diabetes. This is anticipated to more than double by 2025 (1). Four of the

INTRODUCTION

countries in the region – the United Arab Emirates, Bahrain, Kuwait, and Oman – have conducted studies showing their current diabetes prevalence to be among the world’s ten highest countries (1). This increase in type 2 diabetes reflects the rise in obesity and body fat, which play a major role in this metabolic disorder. Presently, the highest prevalence of type 2 diabetes among the GCCs is in Saudi Arabia (7).

Chronic care model The literature suggests that appropriate diabetes treatment with good long-term health outcomes can be enhanced by improving the diabetes health care delivery system at the primary health care level (8, 9). The Chronic Care Model (CCM) is well recommended in this context and was found to provide successful outcomes and widely adopted approaches to improve care based on clinical guidelines with quality initiatives (10). The model has several components and many effective strategies to manage and prevent chronic diseases, and to help health care teams to provide effective solutions to their patients. Additionally, it suggests a guide for higher-quality chronic illness management within primary care. Its components include self-management support, clinical information systems, delivery system redesign, decision support, health care organization, and community resources that can produce system reform in which informed, active patients interact with prepared, proactive practice teams (11, 12). It is also well known that the CCM can play a significant role in restructuring medical care to create partnerships between health systems and communities. However, the CCM still needs future measures in diabetes process indicators, such as self- efficacy for disease management and clinical decision making (13).

Figure 1 illustrates the CCM and its different components of the health care system and the community, which all are essential to lead to improved health care outcomes. My project and the eventual thesis were applied at the level of productive interactions between patients and the team.

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Figure 1. The chronic care model, adapted from ‘Chronic illness and patient self-management’. Behavioural Medicine: A Guide for Clinical Practice, 4th edition, New York, NY: McGraw-Hill; 2014, by Janson, SL et al. (14).

Team-based approach in diabetes management According to current empirical evidence, NCDs, including diabetes, are best managed through a team of care providers with complementary specialities (15). Therefore, a description of skills and how they complement each other is essential to produce productive interactions between the informed, activated patients and prepared, proactive and practiced team members. The team-based approach itself is not a novel concept in health care (16). Research on team- based care has already explored many characteristics of the concept and its core principles and values, which were later supported by the best practices (17, 18). Additionally, the elements or characteristics of team-based care for high performing practices have long been discussed (19). The team-based management went through several development stages and models, starting from the parallel approach, in which care providers contributed to the service in parallel pathways with individual goals to reach an interdisciplinary and integrative approach in which the care providers work collaboratively towards one specific goal [Figure 2]. Each of these models occupies a position along the spectrum from the non-integrative to the fully integrative approach in patient care. The development of the framework into different models happened

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around four key components of integrative health care practice, namely philosophy/values, structure, process, and outcomes (20).

Figure 2. A continuum of team health care practice models. Adapted from ‘Parallel practice to integrative health care: a conceptual framework’. BMC Health Services Research, 2004, by Boom H, et al (20).

Understanding the development of models has important implications for health research, health care managers, and stakeholders of the country, as this could help in the implementation of their components in any hierarchical health care system. The decreasing importance of a hierarchical authority structure and the increasing importance of structures, processes, and outcomes that enhance communication and consensus-building should be considered the most important step in model application. Health care managers in different team- oriented practice models will require different knowledge and skill sets to provide the necessary leadership (20). Nurse-led clinics also occupy an important position within some of the team-based approach models. The nurse- led clinics within team-based management has gained a respected presence globally, and specifically in type 2 diabetes management (21). In fact, the nurse- led clinics has demonstrated that patients’ self-management is improved dramatically (22), especially where physicians’ numbers were recorded to be limited and nurse-led services were initiated. The literature also documented that nurse-led clinics could contribute to other successful outcomes (23-26), if 4

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implemented properly. Such success was demonstrated in other settings (27- 29), and subsequently could provide good results in Oman. Neighbouring countries have shown progressive development in nurses, with supportive programs to place them in advanced practice roles in the coming five years with very supportive patients (30).

According to recent literature, there is a huge difference between the multidisciplinary approach and the interdisciplinary approach, although some studies still use the terms interchangeably (31, 32). The term “multidisciplinary team” refers to activities that involve the efforts of different members of the team from different disciplines. The members of each discipline will be working towards their own individual goal for the patient, and in general, there is little or no overlap between the team members (33). The interdisciplinary team members not only require the skills of their own disciplines, but also have the added responsibility of the group effort on behalf of their activity or patients’ involvement. This effort requires the skills necessary for effective group interaction and the knowledge of how to transfer integrated group activities into a result that is greater than the simple total of the activities of each individual discipline (33).

An important concept for team-based management in relation to the interdisciplinary approach is that it provides continuous, accessible, consistent, and effective care focused on an individual patient’s needs and goals (21). Within the team itself, a fundamental principle of the interdisciplinary approach is equality and interdependence between team members (34). The focus is on how different members with different specialties in the team work together in an integrated manner (interdisciplinary) rather than alongside each other (multidisciplinary), and how flexibility is needed with respect to professional limitations and patients’ needs (34). It is essential to identify shared core roles and responsibilities, while differentiating these from the unique contribution of each specialty. Working as a team requires members to be willing and committed to working collaboratively to create an environment that promotes trust and encourages supportive relationships within a work setting that encourages mentoring and ensures that achievements and contributions are recognized as successful partnerships between team members.

Figure 3 presents some key contributors to establishing a successful interdisciplinary approach for diabetes care delivery. These contributors include working collaboratively to foster supportive relationships, strong and committed organizational and team leadership, diversity in expertise with team

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members tailored to local circumstances, shared goals and approaches to ensure consistency of message, clear and open communication within the team and with the patients and keeping the patient at the centre of decision-making.

Figure 3. Key contributors to a successful interdisciplinary team in diabetes care. Adapted from ‘The interdisciplinary team in type 2 diabetes management: Challenges and best practice solutions from real-world scenarios’. Journal of Clinical and Translational Endocrinology, 2017, by McGill M, et al (21).

A strong and supportive organizational leadership that is committed to the interdisciplinary approach is always required within team-based management. This is important at a team level, in which leadership has been recognized as an essential element in successful interdisciplinary team delivery (21). Members who are leading the team should be clear on when and how to be a team player. Creativity and adaptability within the team should be encouraged and should depend on factors such as the number of patients involved and resource constraints. It is also important that all members of the team have a voice, no matter how junior or inexperienced they are. While seniority should be respected, junior staff often have innovative and creative ideas that deserve to

INTRODUCTION

be heard. In this way, including every member within the team is encouraged, job satisfaction is improved, and patients’ optimal management is reached (21).

The interdisciplinary team approach could be applied in different forms of distribution of tasks for Human Resources for Health (HRH) management mechanisms: for example, a form of task-sharing, task-shifting or task- replacement, and their application fluctuates according to the HRH workforce capacity, availability and preparations. Task-sharing, for example, is a central process through which team members collectively utilize their available informational resources through discussion structure and cooperation (35). Task-shifting involves the rational redistribution of tasks among health workforce teams. Specific tasks are assigned, where appropriate, from highly qualified health workers to health workers with less training and fewer qualifications in order to make more efficient use of the available HRH (36). Task-shifting from physicians to nurses or other non-medical providers has been identified as a strategy to alleviate shortages and improve quality and efficiency (37). The literature also revealed that if portions of preventive and chronic care services are delegated to non-physician team members, primary care practices can provide recommended preventive and chronic care with panel sizes that are achievable with the available primary care workforce (38). Task-replacement is a complete change of tasks where applicable. This could be applied to certain tasks and mandates that are performed by health professionals, which are completely stopped and replaced by other and different mandates according to the requirements of the service.

Oman and Type 2 diabetes management situation Oman’s geography and demography Oman, officially the Sultanate of Oman, is an Arab State in southwest Asia on the coast of the Arabian Peninsula with a strategic position on the Arabian Gulf. Oman is bordered by the United Arab Emirates, Saudi Arabia and Yemen (Figure 4). In 2018, the estimated population of Oman was 4.83 million (39). This is a sharp increase from the 2010 census estimate of 2.77 million. Nearly 50% of the population lives in Muscat Governorate and the Batinah coastal plain northwest of Muscat Governorate, while 200,000 live in the southern region. There are about 30,000 people in the remote Musandam Peninsula (39).

The largest city and the capital of Oman is Muscat, with a population of around 800,000, followed by Seeb (240,000) and Salalah (165,000). Despite being the 70th largest country, Oman is one of the least densely populated, with just nine people per km2 (39) on a land of 309,500 km2 (40). 7

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Figure 4. Map of Oman. Source: https://www.worldatlas.com/webimage/countrys/asia/om.htm

Oman is a very ethnically diverse country with at least 12 spoken languages that represents its imperial past. Many Omani citizens are from Baluchistan and the Swahili coast, and there are about 600,000 foreigners, mostly guest workers from Egypt, Jordan, Syria, Sudan, Iran, Pakistan, India, Bangladesh and Philippines (41).

The Omani population is relatively young, with around 50% of citizens under 20 years of age. As of 2016, literacy among young Omani adults aged 15-24 is around 98%, with minimal differences between females and males (42).

Oil accounts for 50% of the country’s Gross Domestic Product (GDP), which is estimated at 73 billion USD (43). Health sectors spent around 3.5-4.0% of the country’s total GDP (44). 8

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The government does not keep official statistics on religious affiliation, but around three-quarters of Omanis adhere to the Ibadi section of Islam, while the remaining 25% are either Sunni or Shia Muslims. There are small communities of Indian Hindus and Christians that have been embraced in the country and account for 5% of the country’s population (45).

The climate of Oman is extremely hot and humid most of the year with the exception of Dhofar region (south), which has a light monsoon climate and receives cool winds from the Indian Ocean. Summer begins in mid-April and lasts until the end of October. The highest temperatures are registered in the interior, with more than 50°C in the shade (46).

Omani people’s lifestyle Omani people are known to have sedentary behaviours and low levels of physical activity, especially among females. Unhealthy dietary habits are also common among both genders and contribute to weight gain, and this is found as early as in the childhood stage (47). The consumption of traditional Omani dishes is also known to have effects on high cholesterol, high blood sugar, and weight gain (48). Therefore, there is an urgent need for more research as well as a national policy to promote active living and healthy eating, and to discourage sedentary behaviour among Omani adolescents and adults (49). Additionally, patients with diabetes should consider lifestyle changes to improve their outcomes (50). Along with changes to their diet and physical activities, behavioural changes could also be uncovered. Diabetes management clinics’ improvement could support patients’ holistic development, which is considered a complex process but very worthwhile in the process of improving patients’ outcomes. Substantial evidence suggests that it is possible to change patients’ behaviour, but this change generally requires comprehensive approaches at different levels (physician, team practice, hospital, clinic, wider environment), tailored to specific settings and target groups (51).

Smoking is also common among the Omani population and contributes to an unhealthy lifestyle, which has become very prominent with Omani urbanization (52, 53). Water pipe smoking is also growing rapidly among Omani adolescents and becoming an emergent public health concern. Therefore, efforts to prevent adolescent and adult smoking should be designed with knowledge of factors associated with such behaviour, and should include all forms of tobacco (54).

The risk of type 2 diabetes is reported to start at adolescence and is indicated by a high body mass index (55). Lack of physical activity and knowledge about healthy and energy-dense foods might be considered risk factors for overweight

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and obesity among Omani adolescents, yet there is little data on the lifestyle habits of Omani adolescents and students (56). However, what is found in the literature is still important and encourages monitoring of the lifestyle habits of young adolescents, as recent research has indicated an association between young people’s lack of exercise, unhealthy dietary behaviour, and an increased risk of developing diabetes (57, 58).

Lifestyle changes during the last five decades have influenced the culture, and it has become apparent that certain factors seem to have influenced the Omani population’s anthropometry (49). The problems of sedentary behaviours, limited physical activity or unhealthy eating habits among the Omani population have become major challenges. The promotion of a healthy lifestyle should be a national public health priority. In addition, there is an urgent need for national policy promoting active living and healthy eating while reducing sedentary behaviours among the Omani population. Future research needs to address the determinants of sedentary behaviours, physical inactivity, and unhealthy eating habits (49).

Type 2 diabetes epidemic NCDs, including type 2 diabetes, are a serious concern in Oman due to the consequent outcomes on the population and the health care system (59). Type 2 diabetes in Oman occupies a very frontal place among other NCDs with a recorded prevalence of 20% in one Omani region in 2010 (60). Likewise, it is considered the second most common chronic disease in Oman after cardiovascular diseases (60-62). According to the WHO, Oman will witness an almost three-fold increase in patients with diabetes over the coming years, rising from 75,000 to 217,000 by 2025 (63). The outcomes of type 2 diabetes could be divided into two types: the first type could constitute the common diabetic complications in different body systems, such as blindness and limb amputation, which require family and community support; and the second type could create different sequelae and require bigger contributions from the health care system in the country, such as effective medications and optimal service delivery. Furthermore, diabetes starts early in life among younger Omani adults compared to older adults, and this could pose difficult challenges for diabetes management teams at PHCCs (64), as the disease has to be tackled early in life with strong preventive actions.

The health care system The main health care provider in the country is the Ministry of Health (MOH). Other health care providers include: Armed Forces Medical Services, Royal Oman Police Medical Service, Sultan Qaboos University Hospital, Diwan 10

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Medical Services, Petroleum Development Oman Medical Services, and the private sector (65, 66). The health care system in Oman is divided into three levels: primary, secondary and tertiary. The primary care services involve general physicians, specialized family practitioners, nurses, dieticians, and health educators, in addition to other support staff. The secondary and tertiary health care services involve more specialized health care providers. At all three levels of service, the level of care management fluctuates according to the severity of the patients’ disease and is provided free of charge. The management includes health providers’ consultations, ordering laboratory tests, performing invasive/non-invasive procedures, dispensing medication, and follow-up appointments (66). Patients can approach the health care system through either the public or the private sector. Presently, the private sector is not large and not well developed compared to the public sector in terms of the team-based approach at diabetes management clinics; it represents a small proportion of overall care for diabetes at primary health care level and is mainly localized to the Muscat region (66). Additionally and according to the latest HRH statistics recorded by the MOH in 2017, the number of physicians counted 6,200, nurses 14,408, and other paramedical staff with other unrecorded sub-specialities 9,185 (67). It follows from this that there are 13.6 physicians and 31.6 nurses per 10,000 people.

The team-based approach in diabetes management clinics in the public primary health care system PHCCs at the primary health care system provide three types of health care, namely prevention, management, and promotion of health care to the community (66). The appreciation of the comprehensive health services based on these three components is essential to understand how diabetes is handled. Along with this background, it is also important to mention that type 2 diabetes is addressed using two approaches: the preventive approach with a screening attitude at general practitioner clinics, and the management/promotion approach with basic health care at diabetes management clinics (68).

According to the latest national guidelines, the treatment/management approach at diabetes management clinics at public PHCCs should include primary care physicians, nurses specialized in diabetes, dieticians, pharmacists, psychologists, and podiatrists (68). However, the core members of the project are the PHCPs who were available at the time when the project was conducted. The national diabetes guidelines that are followed at the clinics are based on global recommendations and current evidence for treatment and prevention of type 2 diabetes (68). The general definition of ‘team’, which is followed at diabetic clinics in Oman, is adopted from global understanding of teams, which

INTRODUCTION

is based on individual mandates and specific roles required to be accomplished during service delivery, and this mechanism of teamwork is occasionally associated with well-defined meetings or collaborative actions (69). Previous research conducted in diabetes management clinics in primary health care in Oman and related to team-based management suggested the multidisciplinary team-based approach model, and further requirements for organizing, training, and educating PHCPs were recommended (70-72). However, my expectation that primary health care in Oman is not yet at the multidisciplinary level [figure 2]. Therefore, identification and conceptualization of the teamwork approach among PHCPs with opportunities for service improvement was an essential component in this project.

Knowledge gap and contribution of this PhD project In this project and the eventual thesis, certain gaps in knowledge had to be filled: How do PHCPs 1 understand team-based diabetes management? How do the PHCPs through available HRH management mechanism share tasks related to team-based diabetes management? What do PHCPs at diabetes management clinics think are the best ways to share tasks? Will patients accept non- physician-led management in the context of a hierarchical health system?

This project also fills gaps in diabetes service and provides background information against which feasible mechanisms can be contrasted (including but not limited to task sharing/shifting/replacement), and how to optimize the diabetes management clinics from PHCPs’ and patients’ perspectives.

The project explored challenges related to diabetes management by observing the core roles and responsibilities of the members and the interdependence between them. Additionally, I looked into the contribution from each specialty, leadership within the team, patients’ involvement, and resource constraints.

In the primary health care setting in Oman, it is not known which point the team has reached in its development within the present hierarchical system.

Accordingly, only PHCPs and type 2 diabetes patients were enrolled into this project with a focus on the team-based management component at diabetes management clinics. The screening component at general physician clinics and type 1 diabetes patients who are treated at tertiary care facilities were excluded.

1Available complement of staff for diabetes management at primary health care level: i.e. physicians, nurses, dieticians and health educators 12

INTRODUCTION

Main and specific aims of the studies Main aim The overall aim of this project was to explore team-based management for type 2 diabetes in public PHCCs under the MOH in Oman. Subsequently, it sought to explore the challenges, opportunities for improvement and the most preferable HRH management mechanism that could be applied within the team in the context of providers’ and patients’ perspectives.

Specific aims A. To explore the perceptions among primary health care centre staff concerning competencies, values, skills and resources related to team-based diabetes management and to describe the availability of resources needed for team-based approaches (papers 1, 2, and 3). B. To explore challenges and discuss opportunities for improvement of diabetes management clinics in PHCCs in Oman (papers 2 and 3). C. To explore PHCPs’ perceptions for changes in HRH management mechanisms in diabetes management clinics at PHC in Muscat, Oman (paper 3). D. To explore the perceptions of type 2 diabetes patients towards the current diabetes management visits at public PHCCs in Muscat and their opinions towards nurse-led diabetes management clinics (paper 4).

MATERIALS AND METHODS

Materials and Methods

General project design The project design was based on the Chronic Care Model (CCM) at the level of productive interactions between the informed activated patient and the prepared, proactive practice team [Figure 1], bearing in mind the key contributors to a successful interdisciplinary approach within team-base management in diabetes care [Figure 3]. The project explored PHCPs’ perceptions towards different HRH management mechanisms and type 2 diabetes patients’ opinions towards nurse-led clinics.

The entire project was implemented following quantitative and qualitative research methods at diabetes management clinics at primary health care centres. The first specific aim was designed to be addressed through quantitative and qualitative methods. This involved exploration of the perceptions of PHCPs concerning competencies, values, skills and resources related to team-based diabetes management and to describe the availability of the resources needed for team-based approaches. The qualitative method came to support the exploration in terms of challenges and discuss opportunities for improvement, and PHCPs’ perceptions for changes in HRH management mechanisms in diabetes management clinics at primary health care centres in Muscat, Oman.

Data was collected from registries available at public PHCCs in Muscat Governorate, along with a survey dispensed to all the physicians-in- charge/managers of the PHCCs and the diabetes management core team members available in each PHCC at that time. The survey (Appendix) was designed to reflect the requirements for diabetes management at the primary health care level, as proposed by the National Diabetes Mellitus Management Guidelines, and was piloted in eight centres located in Muscat Governorate.

Fieldwork was conducted by one researcher (Kamila Al Alawi) and four field workers (medical students) who were carefully selected for this mission.

For the second specific aim, a qualitative approach was used, which included non-participant observations for diabetes management consultations followed by semi-structured interviews with PHCPs involved in diabetes management clinics. The non-participant observation approach is able to clarify settings and participant behaviour during the performance of tasks without the observer making any contribution or being a part of the performed task (73). In my

MATERIALS AND METHODS

project, semi-structured interviews followed and supported the non-participant observations, as it is well known from the literature that semi-structured interviews give a lot of information in the form of spontaneous descriptions, opinions and histories (74). During the interviews, participants were given space and freedom to talk with semi-structured guidance. The participants (PHCPs) in my project comprised the core team and additional members working at diabetes management clinics. Both approaches used in this study were designed to identify challenges related to diabetes management and discuss different opportunities for improvement.

The third specific aim was to explore PHCPs’ perceptions of changes in HRH management mechanisms in diabetes management clinics at primary health care centres in Muscat, Oman, looking into the preparedness of PHCPs to adopt at least one of the HRH management mechanisms described by the WHO for the purpose of task management. This aim was also achieved through semi- structured interviews with PHCPs involved in diabetes management clinics.

In the context of the importance of the role of patients in diabetes management clinics and considering them as part of the team, the fourth specific aim was to interview type 2 diabetes patients. Semi-structured interviews were selected to explore these patients’ perceptions towards the current diabetes management visits and their opinions towards nurse-led clinics.

Summary of the studies and eventual papers is shown in table 1.

MATERIALS AND METHODS

Project setting and sample selection The entire project was conducted in the Governorate of Muscat [Figure 5], which has approximate 1.4 M citizens (75). The first study was applied in 26 public PHCCs in Muscat Governorate under the MOH and covered six provinces (Table 2). At the time of conduction of my project, the centres counted 27 public PHCCs (one centre was excluded because it does not conduct diabetes management clinics). The next two studies were conducted in five purposely- selected centres and the last study was conducted in four out of the five centres (one centre was excluded because it does not conduct team-based service). The consultation process was observed and PHCPs and type 2 diabetes patients who are involved in diabetes management clinics were interviewed (Table 3).

Figure 5. Map of Muscat Governorate. Source: https://en.wikipedia.org/wiki/Muscat.

Table 2. Provinces of Muscat Governorate and their populations.

Province Population Muscat 800.000 Muttrah 234.255 Bawshar 40.202 Seeb 240.000 Al Amarat 70.400 Qurayyat 54.387

MATERIALS AND METHODS

Table 3. The participants in the qualitative studies.

Care Providers Observed Consultations Interviews Professions P N D HE O P N D HE O Sex Female 3 4 2 1 2 10 8 2 2 4 Male 1 0 0 0 0 1 0 0 0 0 Age 30-45 years 30-45 years Years of experience 5-20 years 5-20 years Nationality Egyptian, Indian, Omani Omani, Sudanese Language English and Arabic English and Arabic

Patients Sex Female 11 6 Male 6 1 Age 30-80 years 30-80 years Duration of T2D 5-20 years 5-20 years Nationality Omani Omani

P: physicians; N: nurses; D: dieticians; HE: health educators; O: others (pharmacist, assistant pharmacist, psychologist and medical orderly); T2D: type 2 diabetes.

Studies’ Methods Cross-sectional survey (Study 1) The choice to conduct a self-administered survey was based on the type of information needed for this project. It is known from the literature that for collecting information about services, people, community that include figures and demographic data, a survey is the best option (76). It also protects respondents’ confidentiality and allows them to respond in their own free time (77).

The research team designed a cross-sectional survey to mirror the national diabetes guidelines available at that time (Appendix). The survey included three main sections. The first section was designed to include data from the available (manual and electronic) registries and had ten questions. The second section was purposely designed to include data from the physician in-charge/manager of the PHCC and comprised two parts: the first part included seven questions to elicit information related to PHCPs, and the second part included 22 questions to elicit information related to the availability of resources for screening, diagnosis, and monitoring of diabetic patients and to control and delay the diabetes complications in PHCC. The third section was designed to include data about PHCPs involved in the diabetes management clinic (core members) and also comprised two parts. The first part included 11 questions with information 19

MATERIALS AND METHODS

related to PHCPs’ characteristics, such as gender/sex, age, nationality, qualifications, designation, training in diabetes and awareness of national guidelines. The second part was in the form of a four-point Likert scale with 31 items. Later, the 31 items were categorized into four themes (Table 4).

Table 4. The four themes including the categorized 31 items.

Themes Items PHCPs’ self- 1. I have up-to-date knowledge to conduct diabetes perceived management clinics. competencies 2. I have up-to-date skills to conduct diabetes management clinics. 3. I consider myself as a resource for diabetic patients. PHCPs’ self- 1. I am responsible to provide up-to-date knowledge and skills perceived values for diabetic patient. 2. I perceive patients’ education as an important factor in diabetes management. 3. I consider patients’ self-management as an important part of diabetes management. 4. I value communication with diabetic patients. 5. I respect diabetic patients’ beliefs in regard to their disease. 6. At my PHCC, we consider building PHCPs’ capacity very important to provide the recommended diabetes management. 7. I am committed to MOH and PHCCs in terms of providing the recommended diabetes management. 8. The culture of PHCCs in Oman helps me in providing the recommended diabetes management. 9. As a professional provider, I have a good effect on patients’ decisions related to diabetes management. 10. My nationality can affect patients’ decisions related to diabetes management. PHCPs self- 1. At my PHCC, we provide team-based diabetes management. perceived team- 2. I consider myself part of a team when providing the related skills recommended diabetes management. 3. I consider myself a leader in the diabetes management team. 4. I accept inter-professional relationships in the diabetes management team. 5. I have a chance to reflect on patients’ decision related to diabetes management with my colleagues. 6. I encourage teamwork related to diabetes management. 7. I have the ability to deliver teamwork related to diabetes management. 8. I value teamwork related to diabetes management. 9. I encourage collaboration action in related to diabetes management. 20

MATERIALS AND METHODS

Table 4. The four themes including the categorized 31 items. -continued

Themes Items PHCPs self- 1. I ensure that I have time to update my diabetes knowledge perceived - and skills. support/resources 2. I have an easy access to the internet to update my diabetes knowledge. 3. I have been supported financially to update my diabetes knowledge (attending courses in diabetes). 4. My manager supports me in updating my diabetes knowledge. 5. My colleagues support me in updating my diabetes knowledge. 6. I believe that the infrastructure of PHCCs in Oman helps in providing the recommended diabetes management. 7. At my PHCC, the work environment is helpful in delivering the recommended diabetes management. 8. At my PHCC, we have the appropriate human resources to conduct the recommended diabetes management clinic. 10. At my PHCC, we have the appropriate technical resources to conduct the recommended diabetes management clinic.

The survey was piloted in the Seeb province of Muscat Governorate, and then distributed to all the provinces of Muscat Governorate by the researcher and four field workers. The researcher conducted several meetings with the field workers before and after distribution of the survey. These meetings aimed to provide an in-depth understanding of the survey and overcome any challenges that the field workers might face during data collection.

MATERIALS AND METHODS

Qualitative non-participant observations of diabetes consultations (Study 2) The study was started with non-participant observations of diabetic clinic consultations followed by semi-structured interviews with PHCPs.

Figure 6. Primary health care providers’ tasks and roles (a nurse examining the feet of a diabetic patient, and a medical orderly confirming patients’ appointments).

The non-participant observation protocol was designed in advance to document PHCPs’ behaviours during consultations. The literature suggests that such protocols should be suitably designed to enable researchers to collect data without being part of the actions that are being observed (73). The observation protocol involved collecting two sets of data. The first set involved collecting information related to PHCPs’ and patients’ characteristics, such as gender/sex, age, how long the patient has had the disease, profession of the PHCPs, nationality of PHCPs, and how long the PHCPs have been involved in conducting the clinics. The second part involved recording observations about a list of items related to the provider’s tasks and roles [Figure 6]. The items included on this list were as follows: performance of different tasks/responsibilities, performance of management tasks, and performance of external transfers/referrals if required. The first part of the protocol was used as the background for the second part, and if the patients were sent to another consultation room, laboratory or pharmacy in the centre, the researcher 22

MATERIALS AND METHODS

followed them without interference with the team or the management provided. During the process, 13 PHCPs (12 females and one male) and 14 type 2 diabetes patients (13 females and 1 male) were observed during different consultations within diabetes management clinics. The PHCPs were 30‒45 years, with 5‒20 years of experience, and different nationalities. The patients were 30-80 years old with different levels of education and employment states (Table 3).

Qualitative interviews with health care providers (Studies 2 and 3) The interview guide for study 2 involved questions related to the organization of work in the diabetes management clinic, the informal mechanisms for work organization, and the relationship between the health care providers and their professional role [Figure 7]. The main focus was to identify different problems/challenges that might occur with the current work organization or between the professionals and discuss opportunities for improvement. The non- participant observations were used as the background for the interviews to further explore the challenges related to diabetes management clinics, which might have direct or indirect connections with team-based management and might have consequences for the community.

Study 3 included the same PHCPs as in study 2. However, in this study, the researcher wanted to explore care providers’ perceptions towards different HRH management mechanisms that are already available in other settings in the world. These mechanisms were found to have certain strategies for solving health system challenges related to the health workforce: for example, shortage of physicians or unavailability of appropriate number of care providers. The interview guide involved questions related to HRH management mechanisms in diabetes management clinics as follows: whether any official management mechanisms for HRH are known, whether task-sharing, task-shifting or task replacements are considered solutions for shortage in HRH at diabetes management clinics (literatures’ definitions of the three different task mechanisms were provided for those who were not aware of them), what is the opinion on HRH management mechanisms between members of the diabetes management team and what are the requirements and future outcomes on HRH management mechanisms if implemented in public PHCCs in Oman?

For studies 2 and 3, semi-structured interviews were selected because they have been described in the literature as allowing the participants to talk, to think, and express themselves freely, with some structure as to what has to be covered, while allowing the conversation to change substantially between the participants (78). A total of 27 PHCPs were interviewed for both studies (Table 3).

MATERIALS AND METHODS

Figure 7. Interview in progress with a primary health care provider.

Qualitative interviews with type 2 diabetic patients (Study 4) This pilot study came into the project to complete the circle of diabetes management teams at public PHCCs. In four PHCCs, seven type 2 diabetic patients aged between 30 and 80 were interviewed. The interviews explored these patients’ perceptions towards their visits to the diabetes management clinics and their opinions of nurse-led clinics. The patients’ selection was done from the morning and afternoon patients’ registration list. The patients were interviewed after finishing their service. The patients who were involved in the project were one male and six females, with different employment status (one student, one employed individual and five housewives) and different levels of education (basic education and university education). The interview guide was designed in advance with the following questions: What is your perception towards the public primary health care service provided to you as a diabetic patient? What is your perception of the tasks performed by the members of the team in general during diabetes management visits? Have you experienced any positive/negative encounters during your interaction with care providers? Are there any tasks that could be performed differently or by different care

MATERIALS AND METHODS

providers? What would you think if some of the tasks performed by a physician were transferred to a nurse, and what is your opinion on nurse-led clinics in the primary health sector in Oman? The nurse-led clinic concept was introduced to the patients in the form of suggestions supported by evidence-based outcomes. The interviews with patients followed the same semi-structured method as did those with PHCPs (78).

Studies’ data analysis Statistical analysis (Study 1) A non-parametric approach was used to analyse the data. For categorical variables, frequencies, and percentages were reported. For continuous variables, medians with minimum and maximum values were reported. Associations between characteristics were evaluated using the Mann-Whitney U test and the Kruskal-Wallis H test of association. All the statistical analysis was carried out using SPSS Statistics (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.).

Descriptive summaries and qualitative content analysis (Study 2) All the observations were summarized into descriptive summaries. All the interviews were transcribed either in English or in Arabic by professional transcribers. Then, the main researcher (Kamila Al-Alawi) translated the interviews or parts of the interviews from Arabic to English. The transcripts were analysed following manifest content analysis (79) supported by an inductive approach. The manifest content analysis was based on close statements of the care providers’ words without extensions to the underlying meanings of what the care providers said. Texts dealing with challenges related to diabetes management clinic and the implications of the challenges (outcomes) were identified as meaning units that were condensed, interpreted, and labelled with codes. The identified challenges with similar content were developed further into sub-categories and categories, and the implications of the challenges were listed as groups for each sub-category. Finally, the categories were further grouped to be included into one of two contexts.

An example of the manifest content data analysis that was performed is shown in Table 5.

MATERIALS AND METHODS

Table 5. Example of the coding process.

Meaning Condensed Coded Unit Sub- Categories Context Unit Unit (Outcome) categories

‘Sometimes I Staying after Inefficient Shortage of Infrastructure Health have to stay working management computers Care after hours, Centre working using one hours to computer, finish my physician job in first. entering patients’ information into the computer, as during the service, the doctor was using the computer. We have only one computer’

Qualitative thematic analysis (Studies 3 and 4) The analysis process was performed at the manifest level where the coding took place around the data as it was provided in the interviews (80). Then, the themes of analysis for the two studies were identified through an inductive process. The thematic analysis for study 3 started by introducing all the transcribed interviews into the open-code computer program (5). Using this program, the data went through further analysis. The researcher explored the program’s function with study 3 but found it to be time consuming. Therefore, the analysis for study 4 was done manually, as there was limited time left for the project. In both studies, the first step in data analysis was the development of codes. The researcher developed the initial codes after reading the complete set of data. The initial codes were shared with the co-researcher (Helene Johansson) for review. Codes were later grouped into sub-themes and later developed into one main theme. The analysis process was guided by the literature (80, 81). In study 3, the research team developed one overarching theme and four sub- themes. In study 4, the research team developed two main themes, and further, the second theme was developed into three sub-themes.

MATERIALS AND METHODS

Ethical considerations The entire project (four studies) was submitted to the National Ethical Committee in the MOH for approval and clearance was received accordingly. All information collected in the project was treated confidentially. All transcribers for Arabic and English languages were selected on a professional basis. All sound files and transcripts were stored only in a password-protected computer with personal identifiers removed. Participants were fully briefed before starting the interviews using an approved consent form, which was in two languages and included consent to record the interviews. All the participants had an equal right to withdraw at any stage of the research project. The data collected in the project were shared only with the researchers involved in the project and under strict authorities.

RESULTS

Results

This chapter presents a summary of the main findings from the four studies. It begins by presenting the main findings from the quantitative study (study 1) in which the perceptions of PHCPs towards their competencies, values, skills, and resources related to team–based approach at diabetes management clinics were explored. Then, the main findings from the qualitative studies (studies 2, 3, and 4) are provided, including some of the challenges explored at diabetes management clinics, the most preferable management mechanism among PHCPs and opinions towards nurse-led clinics.

Competencies, values, skills and resources related to the team–based approach: PHCPs’ perceptions (Study 1) In the context of the rapid growth of type 2 diabetes in Oman, it was important to understand whether the PHCPs of the core diabetic team and the resources at the PHCCs were well adapted to conduct team-based diabetes management clinics. Data from the centres and managers revealed that a total of 300 primary care physicians (81% females), 411 nurses (99% females), 25 dieticians (100% females), and 20 health educators (100% females) were registered in 26 PHCCs in Muscat.

A total of 115 (38%) of the physicians were involved in providing diabetes management care. Corresponding numbers for nurses, dieticians and health educators were 86 (21%), 23 (92%), and 20 (100%), respectively.

A total of 91 (79%) of physicians, 80 (93%) of nurses, 22 96% of dieticians and 19 (95%) of health educators responded to the survey. The 32 staff who were not included in the survey were on official leave. Thus, the response rate among all individuals that were available was 100%.

Among physicians, 73% were female. All nurses, dieticians, and health educators were females. The main nationality of physicians was Omani (n = 51, 90% females); the others were recruited from different Asian and African countries. The other staff included were mainly Omanis, with only 11 Indian nurses. Among the staff, 79 (37%) had specialized qualifications. Among physicians, 56% were specialized; corresponding percentages among nurses, dieticians and health educators were 6%, 65%, and 43%, respectively.

Data from the core members of the diabetes team (physicians, nurses, dieticians, and health educators) will be presented according to the four themes:

RESULTS

staff self-perceived competencies, staff self-perceived values, staff self-perceived team-related skills, and staff self-perceived support/resources (Table 4).

PHCPs’ self-perceived competencies All staff reported high self-perceived competencies. A maximum score of 100% was reported from health educators regarding having up-to-date skills to conduct diabetes management clinics. A minimum score of 85% was reported from nurses regarding considering themselves as useful resources for diabetic patients.

PHCPs’ self-perceived values Staff believed that they were responsible for providing up-to-date knowledge and skills. They also considered patients’ self-management as an important part of diabetes management. The minimum scores were recorded among health educators and nurses in regard to the provision of up-to-date knowledge and skills for the patients and patient self-management. With the exception of 74% of health educators, the majority of respondents across all professions (94%) agreed that they respect diabetic patients’ beliefs in regard to the disease. Approximately 91% of the staff perceived capacity-building, providing the recommended diabetes management and having a good effect on patients’ decisions as very important, with lower scores recorded among nurses, dieticians, and health educators. Around 75% of physicians, nurses, and health educators indicated that the culture of the primary care centres helps in providing the recommended diabetes management. By contrast, among dieticians, only 55% agreed on this. Finally, the professional groups agreed on the concept that their nationality can affect patients’ decisions (range: 50% of physicians to 91% of dieticians).

PHCPs’ self-perceived team-related skills Across all professional groups, 93% agreed that they considered themselves part of the team, with the lowest scores among nurses (88%). Seventy-three percent of physicians, 64% of nurses, 41% of dieticians, and 61% of health educators surveyed considered themselves as leaders in the team. The majority of the professionals in each group agreed to the idea of accepting inter-professional relationships in the diabetes team and encouraging teamwork related to diabetes management. Furthermore, the majority of the professionals in each group agreed that they have the ability to reflect on patients’ decisions related to diabetes management and deliver care as part of a team. All professional groups also reported that they value teamwork related to diabetes management and encourage collaboration, though nurses reported lower scores.

RESULTS

PHCPs’ self-perceived support/resources Seventy-one percent (range: 41% of dieticians to 84% of physicians) of all professional groups agreed that they have easy access to the internet in order to stay up-to-date on diabetes knowledge. Among all professional groups, 38% agreed (range: 33% of dieticians to 43% of physicians) that they are supported financially in order to update their diabetes knowledge. Ninety-one percent of participants (range: 86% of dieticians to 92% of physicians) considered their manager and colleagues supportive of continued education in diabetes. In the four professional groups, 76% (range: 45% of dieticians to 83% of physicians) considered the infrastructure and work environment helpful in providing the recommended diabetes management. The physicians (67%, 63%) and nurses (68%, 53%) evaluated human and technical resources respectively lower than the other professional groups, dieticians (77%, 68%) and health educators (79%, 68%), respectively.

Additionally, physicians scored highest in the first three themes compared to other PHCPs. Physicians considered themselves to have better competencies than nurses and dieticians. Physicians also scored higher on team-related skills and values compared to health educators. In terms of team-related skills, the physicians perceived themselves to have better skills than did nurses.

The weak members within the team fluctuated between nurses and dieticians. The dieticians reported the lowest scores in team-related values, skills and resources. On the other hand, the nurses, in addition to be the least specialized members in the team, scored the lowest in competencies.

Challenges and opportunities for improvement in diabetes management: PHCPs’ perceptions (Study 2) Team-based approach within different models of service delivery at diabetes management clinics The results from the observations revealed that PHCCs have three models of service delivery in diabetes management clinics: 1) a regular combined morning diabetes and hypertensive management model, 2) a sole afternoon diabetes management model in addition to the first model, and 3) a general model, where type 2 diabetes patients are received with other different diseases. These models represented all the models available in Muscat Governorate. The first model represented 26/26 PHCCs. The second model represented 11/26 PHCCs and the third model represented one PHCC, while none of the PHCCs conducted an afternoon model only. It was clear to the observer (Kamila Al Alawi) that the four core members of the team (physician, nurse, dietician, and

RESULTS

health educator) and the additional members (pharmacist/assistant pharmacist, psychologist, medical orderly) who were involved in diabetes management clinics were appointed with different tasks and mandates. These tasks involved their regular diabetes management posts: for example, history taking, diabetic foot examination, full body examination, blood sugar testing, collecting dietary plans, and discussing prevention plans.

The four core members were available in the majority of the first model; however, they were missing in the third model, and the clinic was led by a single physician. The four core members (where applicable) in the first model functioned in the clinics under the physician’s leadership and tried their best to perform their task and roles towards their individual goals. Therefore, in the presence of the complete team, their performance of their duties was still independent, without referring to the shared goal. So, the main core members, despite their availability in the first model, could not achieve the optimum management for the diabetic patients, and the third model adopted a single- provider approach.

The second model included additional members, such as pharmacists/assistant pharmacists, psychologists, and medical orderlies as well as the core team to overcome some of the challenges presented in the first model. It was shown to be more efficient in terms of team-based approach; however, the PHCPs still could not provide interdisciplinary approach explicitly. The challenges that were solved at the clinics in the first model were in the form of shared rooms, shared computers, and the challenge of defaulters. However, other challenges with different possibilities for improvements and interventions related to nurses’ interests, knowledge, and skills in diabetes management were repeatedly raised.

Challenges exposed during the interviews The interviews confirmed some of the challenges that were observed and further exposed other challenges related to PHCCs, PHCPs, patients, and the community. Challenges that were confirmed by the interviews at the diabetes management clinics highlighted the constricted structure of the centres, with shortage of computers.

‘Sometimes I have to stay after working hours to finish entering patients’ information into the computer, as during the service, the doctor was using the computer. We have only one computer: if another computer were provided, this restricted situation could be solved.’

(Nurse 1, Omani, 1st and 2nd models of service delivery) 32

RESULTS

The opportunities for improvement were discussed in the context of regular evaluations and frequent updates by the MOH to the diabetes management clinics.

Other challenges that were exposed during the interviews were medications and update to the pharmaceutical companies.

‘Medications are an issue: they are very limited for us. I have been practicing for the last 17 years as a primary health care physician, and we still have the same medications that we had then. Diabetic cases have increased and we have more patients and greater incidences in younger patients, but still we have the same medications. I think pharmaceutical companies in general should be improved so the medical management could be complete and our patients could continue to visit us and our pharmacy instead of outside pharmacies.’

(Physician 1, Omani, 1st model of service delivery)

PHCPs’ availability in the diabetes management clinics and their capabilities was a concern. Physicians’ main concerns were nurses’ lack of interest, knowledge and skills in diabetes management, while among nurses, the greatest concern was lack of acknowledgment from higher authorities.

‘For some people it (diabetes) is not a fascinating subject. Still, you should train people who have interest in the subject. I think they should select nurses who have interest, not just for a promotion or selecting a fixed job. Otherwise our nurses who are trained in diabetes will not bother to apply their skills, and these skills will be lost.’

(Physician 2, Omani, 1st model of service delivery)

‘Coming back to the nurses, there are some issues. They are under-trained, they just go to certain workshops to gain skills. Some of them are not aware about simple drugs that are used in diabetes. At least the mechanism of action in cases of hypoglycaemia should be well known. Likewise, medications that cause hypoglycaemia should be known. Health professionals should know things like these. I think they should be more utilized and better equipped and trained, and they will be of great help for us, as management of diabetes requires teamwork. Otherwise it will be critical to delegate any work to them.’

(Physician 3, Omani, 1st model of service delivery)

RESULTS

Providers such as psychologists, dieticians, and pharmacists reported challenges in the registration systems, educational tools, and communications.

‘I do not have proper resources and educational tools that can help me in my clinic and the ministry should look into that. The patients are not encouraged to see me because of this: they prefer to go to private clinics and pay to see a dietician because she/he has everything. So, it is difficult to say that the patients in our clinic are fully educated.’

(Dietician 1, Omani, 1st model of service delivery)

The challenges that appeared in the community were in the form of weak compliance with medication and unhealthy lifestyle among the patients. Reduced patient self-management and support were also reported and were considered a consequence of poor team-based management at the clinics. The opportunities for improvement were discussed in the context of holistic team- based approach at the diabetes management clinics.

‘It is very difficult for patients who have diabetes to perform healthy dietary commitments. They are more committed to the Omani food and culture.’

(Health Educator 1, Omani, 1st model of service delivery)

Task-sharing mechanism and its complete implementation: PHCPs’ perception (Study 3) One main theme was raised from the data: “Yes to human resources management mechanisms, but no to complete implementation yet”: this indicated that HRH management mechanism implementation is feasible, but needs certain requirements. The task-sharing HRH management mechanism was the most favourable mechanism of the three recommended mechanisms: the others being task-shifting and task-replacement. This preferability was due to the fact that the mechanism was already partially adopted in the diabetes management clinics between physicians and nurses. The further discussion between the PHCPs revealed many positive outcomes in the presence of some worries (Table 6).

RESULTS

Table 6. Task-sharing preferability, positive outcomes, worries, and requirements.

Yes to HRH management mechanisms, but not to complete implementation yet Preferable task- Positive Why not yet now Requirements sharing outcomes from (worries) needed for task- mechanism task-sharing sharing mechanism to be implemented  Task-sharing is  Solving the  Insufficient nurses’  Clear plan from already waiting time qualifications. the ministry. performed in the problem at the  Incompetent  Clear policies for clinics to some clinic. nurses’ skills. the team extent.  Improving  Patients’ refusal members.  Task-sharing now diabetic patients’ towards the task  Diabetes is performed management sharing. management between visits.  Patients’ anger to clinics need proper physicians and  Involving patients see nurse instead of preparedness. nurses. more in their physician.  Trust and build-up  Task-shifting not disease (part of  Patients’ negative between health possible. the team). compliance towards care providers.  Task-  Involving nurses the change.  Update to nurses’ replacement is to become  Omani culture as a job description. not applicable. practitioners. barrier.  Update to nurses’  Improving training and close physicians’ role in follow-up. the diabetic team (focused role).

The discussion of the positive outcomes provided good support for the team- based approach; however, the PHCPs expressed several worries if it were implemented completely and instantly in Oman. The main concern among physicians was related to nurses’ capabilities and the main concern among nurses was patients’ acceptance. The other members of the team – dieticians, and health educators – supported the task-sharing mechanism between physicians and nurses in terms of solving some of the challenges, such as time management and reduction in physicians’ workload at the clinic. The physicians, despite their worries, have shown very good support towards the nurses. This support came in the context of patient categories A, B, and C in diabetes management, which already exist in MOH. Category A included well- controlled patients, who could be handled by the nurses, while categories B and C needed to be managed by physicians.

RESULTS

’At the moment, we have patient categorization. We have categories A, B, and C. Category A includes the well-controlled patients and category C includes the very complicated patients. We can categorize B and C for the physician and A for the nurse. Patients who are very well controlled (A) can also be seen once a year by a physician and the nurse can conduct the follow-up visits, but at the moment the nurses are not well equipped to follow up the well-controlled patients alone.’

(In-charge physician)

The nurses’ concern was patients’ acceptance; however, they revealed that with certain requirements, such as clear criteria, proper training and follow-up, the mechanism could work.

’We need clear criteria as to who does what and when; otherwise it (task sharing) will not work.’

(Nurse)

The current diabetes service and nurse-led clinics: Type 2 diabetes patients’ opinions. Type 2 diabetes patients had positive experiences towards the current diabetes management clinics. The positivity came in terms of PHCPs’ roles, tasks, and mandates. However, their opinions towards nurse-led clinics were diverse. Accordingly, three types of patients were identified in the context of acceptance, acceptance with reservations or pre-requirements and complete rejection towards nurse-led clinics.

‘The nurse definitely knows what she is doing and I experienced her service since my first visit to the centre, since my diagnosis, so I would not mind if nurse-led clinics were applied’.

‘I have no problem with seeing the nurses running the clinic provided that they have good knowledge and experience’.

‘I would be scared if I were told that I would see a nurse on my visit, because I do not know if the nurse is qualified to see patients independently’.

The results revealed that concerns towards nurses were related to their knowledge and experience in diabetes management.

RESULTS

Dissemination of results Data dissemination transpired through scientific papers and a conference poster presentation at an international conference.

Figure 8. Poster presentation at 20th European Congress of Endocrinology.

Figure 9. Published scientific papers (1 and 2). 37

DISCUSSION

Discussion

The current situation (Studies 1 and 2) As of 2017, the burden of NCDs accounts for 70% of all deaths in Oman (82). The WHO has clearly stated that all national and international health policies related to NCDs should be based on valid scientific evidence and this evidence requires research. Nevertheless, the application of new knowledge, interventions, technology or reconceptualization of evidence derived from the research have to succeed and have a massive effect on preventing and managing NCDs (83).

This project exposed the challenging situation related to type 2 diabetes at diabetes management clinics at public PHCCs in Oman. The core members’ perceptions towards their competencies, values, skills, and resources related to diabetes management within the team-based approach was dissimilar, with concerns demonstrated between dieticians and nurses. These concerns were associated with low nurses’ specialization and misunderstanding of the leadership concept among the members, which should usually be present within the team (84). The situation is no different in other Gulf Council Countries (GCCs), which also face challenges in their healthcare delivery systems due to different competencies among the staff, and this was revealed to be because of staff’s different training backgrounds (85). Shortages of physicians and nurses have also been revealed in GCCs; however, support for the team-based approach and the availability of many disciplines in the presence of well- developed leadership has been clearly acknowledged (85, 86).

Further challenges that were uncovered and were related to PHCCs, PHCPs and the community were in the form of inefficient medication, lack of diagnostic tools, and invalid registration systems. These could be considered as additional obstacles that prevent efficient management. The literature has recognized such obstacles and has proved that glycaemic control cannot be achieved if certain obstructions steadily present in the clinics and block provision of the service (34, 87).

In fact, the number of patients with type 2 diabetes is continuously increasing and glycaemic control is continuously failing to reach the recommended goals (52, 86, 88). In this regard, the literature has identified practical concepts to support health care service and health care providers to overcome such obstacles and achieve these glycaemic goals, and indeed to support my project, such as adopting a holistic, interdisciplinary approach in diabetes management, in addition to many others identified. Some noteworthy examples include: targeting the underlying

DISCUSSION pathophysiology of type 2 diabetes, treating it early and effectively with combination therapies, and improving patients’ understanding of type 2 diabetes (89).

Implementation of these recommendations should reduce the risk of diabetes‐ related complications; improve patient quality of life and impact more effectively on the increasing healthcare diabetes team-based approach, all of which are well-supported by CCM (90). In my project, the main concepts for quality service delivery were missed: the team-based approach was identified, but with many disciplines, which consequently led to individual goals and misconstruction of patient-centeredness. These two main findings and many more that had been discussed could have been avoided if efficient teams were available at the PHCCs.

Understanding of the team kinetics (Studies 1, 2, and 3) Although the national diabetes guidelines are in place, the teams involved in providing the management are misinformed. The available PHCPs involved in diabetes management in the project had different perceptions towards the team-based approach. Therefore, their approach within the team was different. Additionally, the team kinetics among the members that have been seen delivered the message that members’ individual tasks were their main concern, superseding team concerns.

The literature has confirmed that the group activity of a team should be synergistic, producing more than each member could accomplish individually and separately (32, 33). This could include communications, engaging in interactive problem-solving, and the ability to translate findings of patients with basic education to care providers who are untrained in the techniques that are used. Among our PHCPs, the definition of ‘team’ was not clear, or was clear but not effectively executed, or could not be executed due to different members’ capabilities within the team. The leadership concept was not clearly expressed among the PHCPs and the project has shown that the level of productive interactions between patients and the team as recommended by Chronic Care model (CCM) was not fully achieved.

Despite the preferable (task-sharing) HRH management mechanism that was chosen by the PHCPs to be completely implemented, unwelcome outcomes will continue to emerge if the PHCPs continue to work as a group but individually. Similarly, the tasks will be fulfilled only according to their specialties without interconnectivity to the team goal. The PHCPs clearly exposed their concerns towards complete implementation of the desirable mechanism, stating their worries about unprepared nurses and patients; however, the team kinetics,

DISCUSSION which in my opinion played a critical role, were not among their worries at all. The literature confirms that any change in health care system delivery necessitates certain requirements (91). In my project and according to PHCPs, execution of teamwork requires certain skills from team members and agreements from patients, and in Omani culture, this cannot be achieved at this stage. Additionally, in study 3, the patients’ understanding of complete implementation of the task-sharing mechanism within team-based approach was considered by PHCPs as the most important step in diabetes management. The importance was associated with patients’ involvement with the team and providing productive team kinetics within Chronic Care Model (CCM), which eventually will provide more time to the patients, competent service and improved patients’ self management. The literature connects many important steps in health care development in GCCs to misinterpretation of religious decrees (fatwas) (92). However, patients’ involvement in their disease management could motivate lifestyle changes and provide empowerment aspirations for health care plans, and would do much better in improving the quality – not just the quantity –of the health care system (93).

The missing link of the team (Studies 1, 2, and 3) The literature declared that any team must have a leader: a person who is capable to lead the team and execute its function and has a clear understanding of the leadership concept (94). In my project, the core PHCPs all identified themselves as leaders. This caused another challenge for the team in not executing its mandates, as the presence of multiple leaders in the field can destroy team dynamics and cause confusion about the members’ roles (95). A systemic review conducted in the Middle East and related to interprofessional collaboration and care management of type 2 diabetes patients emphasized the importance of leadership among the health care staff (96). Additionally, the literature related to health care systems stresses that in many settings in the world, nurses are the leaders in chronic care settings (84). Furthermore, the experience of many efforts to improve chronic care indicates that nurses, not physicians, are the key to implementing chronic care management in a patient- centred care team. By the nature of their education and role, nurses are in a position to champion transformation of chronic care (84). In my project, I noticed that physicians had concerns towards the nurses as members of the team. This could be due to their inadequate knowledge and skills in diabetes management or to their poor understanding of team-based knowledge. These findings were revealed in the first three studies, and supported to some extent by patients’ perceptions in the fourth study. Dieticians were also members of a concern in the first study; however, according to physicians, their role was not seen as an obstacle within the team-based approach. This could be due to their

DISCUSSION minimal involvement within the team or due to their absence in the current task-sharing mechanism between them and the physicians.

The nurses’ responses to the blame for their weak performance were in the form of redirecting their weaknesses into their training, non-acknowledgment from higher authorities and diabetic patients’ service preference to see physicians during their visits instead of just nurses. The nurses in my project added that in order to move towards an appropriate team-based approach, they must be empowered by higher authorities and diabetic patients’ support. Additionally, acceptance and contribution to the process must be noticeable in order for the transformation to happen appropriately and steadily in the clinics. The literature has also emphasized that nurses’ empowerment is sometimes associated with affective commitment and job satisfaction (97, 98); however, job satisfaction was not measured in this project and it is not known whether nurses’ weakness could be associated with job dissatisfaction.

Type 2 diabetes patients and nurse-led clinics (Studies 3 and 4) Many evidence-based suggestions for diabetes management clinics could achieve successful implementation and patients-provider interaction (99). Additionally, many improvements to diabetes management clinics could be achieved with patients’ involvement. Some challenges were considered basic and should be improved instantly. Other challenges that require time and other institutes’ involvement should be evaluated carefully for step-wise application.

Patients are considered very important members of the team; therefore, their satisfaction towards the management is essential and it is vital to consider their opinions and involvement in service delivery. Patients’ acceptance of complete task-sharing HRH management mechanism implementation within the team could be a first step towards nurse-led clinics and a solution to the shortage of physicians. In my project, patients expressed positive views towards current diabetes management. However, when nurse-led clinics were explored, the patients showed different opinions. This could inhibit the idea of implementation, but understanding of the factors for inhibition – such as lack of knowledge, concern about the outcomes or unpreparedness for the clinic – could provide another opportunity for discussion and eventual change.

My project has clearly revealed that there are several challenges to service delivery at diabetes management clinics. Therefore, a change in diabetes management clinics has to take place. This also could be achieved in Oman by providing nurses with higher qualifications and responsibilities, as well as taking into consideration the particular structure of the health care system and funding possibilities. Additionally, further research should be carried out to

DISCUSSION investigate the cost-effectiveness of the different models of care at nurse-led clinics (100).

Methodological considerations Numerous methodological considerations were encountered during this project. The research team comprised researchers with different backgrounds and who came from different contexts, but they complemented each other very well in diabetes management knowledge, team-based approach knowledge, quantitative and qualitative research methodologies, and scientific writing. The quantitative and qualitative studies captured numerous challenges in terms of survey/questions construction, collection of data, selection of participants and result presentation.

All the researchers were involved in structuring the survey for the first study. The challenges were mainly encountered with the last part of the survey (the Likert scale question with 31 items). It was very difficult to divide the 31 points equally into the four themes while still locating each point where it should belong. This process involved many sessions of brainstorming and discussions to avoid production of imbalanced themes. However, in the final draft of the survey, the first theme still had fewer points than the others. This did not indicate that other themes are more important than the first one, but just provided fewer points for discussion. After completion of the survey, the pilot phase commenced and was completed by the researcher and four field workers. The co-researcher (Ahmed Al Mandhari) and researcher (Kamila Al Alawi) were heavily involved in the preparation of this process, which included the field workers’ training, conducting meetings to explain the survey questions, where the data should be collected, how to approach the managers of the centres, how long the survey could be left in the centres, and what solutions were recommended if any challenges encountered. Four field workers were prepared with four cars to visit five provinces. The sixth province was approached by the researcher.

All three qualitative studies were executed by the researcher, including non- participant observations and semi-structured interviews. Observations with semi-structured interviews were selected over other methodologies such as Focus Group Discussions (FGDs). This decision was taken in light of the fact that it was almost impossible to gather the PHCPs or the patients after the service provision to conduct FGDs due to time constraints.

Furthermore, due to the hierarchical system at the MOH, the physicians were placed at the top of the system, which allowed them to be very expressive and talkative compare to other PHCPs. Although a professional approach was

DISCUSSION upheld with all PHCPs and in all the research methodologies, still the other PHCPs were not very expressive. Patients were also considered non-talkative and non-expressive: this might be explained by the Omani culture. Therefore, to help all patients individually, the decision was taken to interview them on a one-to-one basis. The selection of patients was more difficult compared to the selection of PHCPs. This was because PHCPs were available in the centre, whereas patients could not commit to particular appointment dates due to difficulties with transportation. Therefore, patients’ participation was based on their random attendance to the clinic.

After arrangement of the observational summaries and the transcripts, the researcher commenced translation (Arabic-to-English) of the interview data. The analysis of data in the first qualitative study (study 2) was performed manually. In study 3, the researcher had a chance to explore a tool for qualitative data coding. The process with the tool was an explorative process and very time-consuming, and due to time constraints, the decision was made to revert to manual analysis for study 4.

The order in which the studies were conducted was appropriate. Study 1 gave the opportunity to explore the situation of diabetes management clinics and the PHCPs’ perceptions in the field. Then, study 2 further explored the challenges and discussed opportunities for improvements related to team-based approach. Studies 3 and 4 discussed the HRH mechanisms with different processes as opportunities for improvement and gathered patients’ opinions towards nurse- led clinics within the team-based approach.

The same PHCCs were chosen for the three qualitative studies, which gave a challenge to the researcher to achieve maximum variation among participants. This could be avoided in the future by selecting different PHCCs for different studies, which hold different aims. All the research methodologies were executed by one researcher, who is an Omani physician at MOH (at the top of the system). Therefore, in the future and to diminish non-expressive participants and increase their confidence to discuss the topic openly, a non- Omani researcher could be a good choice to conduct interviews for further studies.

Presentation of the results in study 4 was a big challenge because of the small sample size, which made it difficult to reach a conclusion. The gender imbalance in both PHCPs and patients was very clear among the participants (with more females than males). However, it is not known whether the results could have been different if more males had been involved.

DISCUSSION

Studying type 2 diabetes, which is a massive epidemic in Oman, enriched the credibility of the project. Involving participants from different specialities, backgrounds, and with different experiences further enhanced this research.

Transferability was enhanced through the description of the setting, the structure of the PHCCs and the diabetes management service, which could allow the results to be applied in other similar services.

In order to connect the current situation of the diabetes epidemic to the team- based approach at the clinic, the specific aim for study 1 was slightly changed from the original plan. Moreover, after receiving a lot of strong results from study 1, which explored challenges related to the team-based approach, the specific aim for study 2 also had to be changed to further explore the challenges by conducting different methodologies (non-participant observations and semi- structured interviews). This process enriched dependability, as the designs of the studies were changed according to findings that arose during the studies. Similarly, after the decision was taken by PHCPs that the task-sharing mechanism is the most preferable mechanism to be completely applied within the team, and specifically, when the task-sharing mechanism between physicians and nurses was strongly considered, it became very important to explore patients’ perceptions towards nurse-led clinics within the team-based approach. Accordingly, the specific aim for study 4 was slightly changed from the original plan.

To enrich confirmability, a lot of quotations have been included in the results and in the original papers. This process allows the reader to evaluate the interpretations made.

CONCLUSIONS AND RECOMMENDATION

Conclusions and Recommendations

Conclusions and contribution of this thesis The team-based approach is an essential component of optimal service delivery at diabetes management clinics. Within this context, my project identified several knowledge gaps related to the team-based approach at diabetes management clinics. First of all, the core members of the team were reluctant to conduct the team-based approach due to many factors, which led to unanticipated execution of tasks rather than productive interactions. Second, the dieticians and nurses (members with concerns) comprehended the situation in the context of limited resources and non-supportive higher authorities, all of which led to non-dynamic teams. However update to the resources, support from the stakeholders in providing comprehensive training for nurses could improve the situation. Additional members to the core diabetes management team could always help, but appropriate utilization of the members who are already available with clear roles and mandates and higher specialization could be more important and could improve diabetes management at PHCCs in Oman. My project showed that the current team-based approach at diabetes management clinics is at collaborative or coordinated level [figure 2]. However, multidisciplinary level and further interdisciplinary level could be reached if properly the needful characteristics of teamwork were gained. Third, patients’ perceptions, understanding, acceptance and involvement in complete implementation of task-sharing mechanisms in diabetes management must be considered essential in the team-based approach, which eventually will help with their outcomes. Fourth, nurse-led clinics within the team-based approach, which were explored in this project, could be explored further to help address the shortage of physicians in Omani PHCCs; however, appropriate preparations are needed. These preparations should be in the form of MOH readiness; PHCPs’ motivation, patients’ clear understanding of their disease, acceptance of the clinics, and their successful outcomes.

Recommendations for future research Future studies that involve nursing education, nursing interests, and the requirements to reform and update nurses’ clinical performance are needed. Upcoming studies on a larger scale on type 2 diabetes patients’ preferences, beliefs, and attitudes towards diabetes management within primary health care system are required. Potential studies on community health and community initiatives related to diabetes health care would be a good step towards improvement in diabetes management. 47

ACKNOWLEDGMENTS

Acknowledgments

First of all, I would like to thank Allah SWT for giving me the health, strength and determination to complete this PhD journey at this age, time, and place, and for allowing me to meet exceptional people who made me stronger, smarter, and more open-minded.

Without the financial support from the MOH in Oman and the provision of a comprehensive scholarship for this project, which ended with a PhD thesis and a degree, this dream would not have been possible.

Umeå University will always have a special place in my heart, with their professors, PhD fellows, lecturers, coordinators, and students.

My specific acknowledgment is extended to the following people, who made the journey possible and special:

My Team

Anna Karin Hurtig (Sweden), my examiner: thank you for your help, support and guidance since the very beginning of my PhD journey and for making it run professionally, with continuous guidance, advice and support at every step and with solutions to many concerns.

Helene Johansson (Sweden), my main supervisor: thank you for all the discussions we had throughout this PhD journey; you tried your best to comfort me whenever I was in a panic, and I really appreciate that. Thank you again for the gift that I received from you in my third year of the PhD journey, which meant a lot to me and always will.

Ahmed Al-Mandhari (Oman), my co-supervisor, colleague and older brother: throughout this PhD journey, you have always been my supporter, mentor, and a good friend.

Margareta Norberg (Sweden): Thank you for joining my PhD journey as co- supervisor in my plan registration, mid-term seminar, and as an author on my first paper. Your knowledge, skills and determination will always be acknowledged. Your experience was very powerful and gave me a lot of insights into this PhD and my future life. Also, I would like to extend my thanks to your husband, whom I met during the dinners at your house. This meant a lot to me.

49 ACKNOWLEDGMENTS

Professors/Associate Professors

Vinod Diwan, Nawi Ng, Anneli Ivarsson, Miguel San Sebastian, Lars Lindholm, Lars Weinhall, Hajime Takeuchi, Isabel Goicolea, Maria Nilsson, Barbara Schumann, John Kinsman, and Klas-Goran Sahlen. Although we did not work closely on any scientific paper, we attended many courses, seminars, and PhD days together and shared a lot of interesting discussions. Thank you for welcoming me into your academic life and allowing me to learn from you. I hope that one day we will meet again and work together with common interests in different projects.

Researchers

Jennifer Williams, Camilla Andersson, Raman Preet, Linda Sundberg, Kristina Lindvall, Fredrik Nortrom, Per E Gustafsson, Anni –Maria Pulkki-Brannstrom, Klara Johansson, Maquines Odhiambo Sewe, Osvaldo Foseca, Fredinah Namatovu, Senia Rosales-Klintz, and Abdullah Al-Muniri, Thank you for your experience, support, feedback, and much more… it has always meant a great deal to me and your tactics helped me a lot in my PhD journey.

PhD students, who just joined and who have finished the PhD journey

Thank you for all the gatherings, dinners, lunches, and activities that we shared together, through which we spent a pleasant time here in Umeå. I wish you all the best in your future life. Remember, each of you is different and comes with your own story, knowledge, skills, and competencies. Comparison is not advisable, but learning from each other is always recommended. Keep in touch through our WhatsApp group: Vijendra Ingole, Vu Duy Kien, Moses Tetui, Moses Arinaitwa, Mikkel Quam, Paul Amani, Nathaniel Sirili, Vincent Rusanganwa, Rackal Gaitonde, Iratxe Perez, Jing Helmersson, Malale Tungu, Frida Jonsson, Aditya Ramadona, Sulistyawati Suyanto, Gladys Mahiti, Julia Schroders, Masoud Vaezghasemi, Ryan Wagner, Kanyiva Muindi, Ida Linander, Anne Gotfredsen, Mazen Baroudi, Mai Vu Thi Quynh, Penipawa Panduleni Shimanda, Chanvo Daca, Edwinah Atusingwize, Helena de Sola Perea, Yue Zhang, Yercin Mamani, Mikael Emsing, Kaaren Mathias, Anna Lundgren, Jean Paul Semasaka Sengoma, Puthy Pat, Paula Kelly-Pettersson, Manal Al- Khanbashi, Samira Al-Rawahi, and Amira Al-Kharusi.

Special thanks to Cahya Utamie Pujilestari, for your special friendship, your delicious soup and prayers; Amaia Maquibar Landa, for pulling me up during my dark days, your beautiful personality, which gave me a lot of strength; Pamela Tinc, for supporting me with your readings of my papers and

50 ACKNOWLEDGMENTS encouraging me to do my best; Septi Kurnia Lestari, for your technical support and friendship; Kateryna Karhina, for your support, presence and help during my PhD journey; Chama Mulubwa, for the morning walks that we had together and laughing loudly at 6:30 in the morning (do you think we were too loud?); Regis Hitimana, for all your valuable advice towards the end of this PhD journey; Daniel Rodriguez, for your support and valuable attendance towards the end of the PhD journey.

Coordinators/Administrators

Birgitta Astrom, thank you for your warm welcome to Umeå University on my first day of arrival. Your kind smile was always on your face whenever I entered your office. Ulrika Harju, thank you for your excellent coordination of my trips, accommodation and transportation. Susanne Walther, thank you for your support and for handling my financial issues very well. Ulrika Järvholm, thank you for your support and for being kind and helpful all the time, especially during my sickness. Angelica Johansson, thank you for your beautiful smile and for being so kind to me whenever I asked you for something. Lena Mustonen, thank you for your kind attitude, approach and technical support.

IT Supporters and System developers

Goran Lonnberg and Wolfgang Lohr, thank you for solving all the technical problems during my PhD journey.

Media and Print

Sonja Nordstrom (graphic designer) and Minna Oscarsson (print service), thank you for supporting me with appropriate design and print services. The thesis would have not reached its final stage without your expertise.

Librarian

Vu, Mai Trang, although I did not use the library physically very often, but only online, I feel proud to have met someone like you. We had one meeting and agreed to meet more, but we left it open. You are a sensational supporter to students, a knowledgeable adviser and a very warm and kind person. You helped me a lot and I want to say thank you.

Ministry of Health, Oman

H.E. Dr. Ali Al-Hanai, saying thank-you will never fulfil your generosity. Your actions and encouragements were always felt and will always be acknowledged.

51 ACKNOWLEDGMENTS

Directorate General for Education and Training (DGET)

Thank you for all the support provided during my PhD.

Royal Hospital

Dr. Qasim Al-Salmi, my boss, thank you for allowing me to continue my studies. Your approval will always be acknowledged.

Lunba, Khalid, Khoula, Irin, Rejimol, Mark and others, my staff, my colleagues and my supporters at the department back home in Oman. Thank you for all the messages, emails, and kind words I have received. They meant a lot to me.

My Family

Hilal Al-Sabti, my dear husband, my encourager and supporter. Because of you, I managed to do this PhD. Thank you for handling the kids while I was in Sweden. Thank you for all the emails, messages, and calls in which you pulled me up whenever I was down, depressed, devastated, and feeling worthless. Thank you for encouraging me to take this degree when it sounded impossible even in my dreams.

Reem (18), Ali (17), Noor (12), and Marwa (8), my kids, I want you to know that you are my fortune. I always kept you in my heart whenever I was travelling, studying, reading, eating or even sleeping. I know it was difficult to leave you for long periods of time and I still remember when you all cried when my first trip to Sweden was scheduled. I know that you all learned a lot by supporting each other in my absence, taking care of each other and your dad, and growing silently but proudly. My PhD journey has ended now, but we will continue to take care of each other physically and spiritually and I hope that you are all proud of me, as I am always proud of you.

Barbara and Khamis, my mom and my dad, thank you for raising me in a unique way, loving education, exploration, and challenges. Without your prayers nothing could have been done.

Kinga, Samira and Azzan, my sisters and my brother, thank you for always being proud of me.

52 REFERENCES

References

1. Internatinoal Diabetes Federation. Diabetes atlas. Brussels: International Diabetes Federation. 2006. 2. González-Clemente JM, Galdon G, Mitjavila J, Miñarro A, Giménez-Pérez G, Mauricio D. Translation of the recommendations for the diagnosis of diabetes mellitus into daily clinical practice in a primary health care setting. Diabetes Research and Clinical Practice. 2003;62(2):123-9. 3. Organization WH. Global status report on noncommunicable diseases 2014: attaining the nine global noncommunicable diseases targets; a shared responsability. Global status report on noncommunicable diseases 2014: attaining the nine global noncommunicable diseases targets; a shared responsability2014. 4. Steyn NP, Mann J, Bennett PH, Temple N, Zimmet P, Tuomilehto J, et al. Diet, nutrition and the prevention of type 2 diabetes. Public Health Nutrition. 2007;7(1a):147-65. 5. Hart CL, Hole DJ, Lawlor DA, Davey Smith G. How many cases of Type 2 diabetes mellitus are due to being overweight in middle age? Evidence from the Midspan prospective cohort studies using mention of diabetes mellitus on hospital discharge or death records. Diabetic Medicine. 2007;24(1):73-80. 6. Dotevall A, Johansson S, Wilhelmsen L, Rosengren A. Increased levels of triglycerides, BMI and blood pressure and low physical activity increase the risk of diabetes in Swedish women. A prospective 18-year follow-up of the BEDA*study. Diabetic Medicine. 2004;21(6):615-22. 7. Ginter E, Simko V. Type 2 Diabetes Mellitus, Pandemic in 21st Century. In: Ahmad SI, editor. Diabetes: An Old Disease, a New Insight. New York, NY: Springer New York; 2013. p. 42-50. 8. Alyaarubi S. Diabetes Care in Oman: Obstacles and solutions. Sultan Qaboos University medical journal. 2011;11(3):343-8. 9. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: The chronic care model, part 2. JAMA. 2002;288(15):1909-14. 10. Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the chronic care model in the new millennium. Health affairs. 2009;28(1):75-85. 11. Barr VJ, Robinson S, Marin-Link B, Underhill L, Dotts A, Ravensdale D, et al. The expanded Chronic Care Model: an integration of concepts and

53 REFERENCES

strategies from population health promotion and the Chronic Care Model. Healthcare Quarterly. 2003;7(1). 12. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288(14):1775-9. 13. Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in US primary care settings: a systematic review. Preventing chronic disease. 2013;10:E26-E. 14. Janson SL, Oka RK, Bodenheimer T. Chronic Illness & Patient Self- Management. In: Feldman MD, Christensen JF, Satterfield JM, editors. Behavioral Medicine: A Guide for Clinical Practice, 4e. New York, NY: McGraw-Hill Education; 2014. 15. Wagner EH. The role of patient care teams in chronic disease management. BMJ. 2000;320(7234):569-72.

16. Baik D, editor Team‐Based Care: A Concept Analysis. Nursing forum; 2017: Wiley Online Library. 17. Mitchell P, Golden R. Core principles & values of effective team-based health care: National Academy of Sciences; 2012. 18. Rowland P. Core principles and values of effective team-based health care. Journal of Interprofessional Care. 2014;28(1):79-80. 19. Ghorob A, Bodenheimer T. Building teams in primary care: a practical guide. Families, Systems, & Health. 2015;33(3):182. 20. Boon H, Verhoef M, O'Hara D, Findlay B. From parallel practice to integrative health care: a conceptual framework. BMC Health Services Research. 2004;4(1):15. 21. McGill M, Blonde L, Chan JC, Khunti K, Lavalle FJ, Bailey CJ. The interdisciplinary team in type 2 diabetes management: Challenges and best practice solutions from real-world scenarios. Journal of Clinical & Translational Endocrinology. 2017;7:21-7. 22. Moser A, van der Bruggen H, Widdershoven G, Spreeuwenberg C. Self- management of type 2 diabetes mellitus: a qualitative investigation from the perspective of participants in a nurse-led, shared-care programme in the Netherlands. BMC Public Health. 2008;8(1):91. 23. Denver EA, Barnard M, Woolfson RG, Earle KA. Management of Uncontrolled Hypertension in a Nurse-Led Clinic Compared With Conventional Care for Patients with Type 2 Diabetes. Diabetes Care. 2003;26(8):2256-60.

54 REFERENCES

24. Wong FKY, Mok MPH, Chan T, Tsang MW. Nurse follow-up of patients with diabetes: randomized controlled trial. Journal of Advanced Nursing. 2005;50(4):391-402. 25. New JP, Mason JM, Freemantle N, Teasdale S, Wong LM, Bruce NJ, et al. Specialist Nurse-Led Intervention to Treat and Control Hypertension and Hyperlipidemia in Diabetes (SPLINT). Diabetes Care 2003;26(8):2250-5. 26. Wong FKY, Chung LCY. Establishing a definition for a nurse-led clinic: structure, process, and outcome. Journal of Advanced Nursing. 2006;53(3):358-69. 27. Gill GV, Price C, Shandu D, Dedicoat M, Wilkinson D. An effective system of nurse-led diabetes care in rural Africa. Diabetic Medicine. 2008;25(5):606-11. 28. Mason JM, Freemantle N, Gibson JM, New JP. Specialist Nurse–Led Clinics to Improve Control of Hypertension and Hyperlipidemia in Diabetes. Diabetes Care 2005;28(1):40-6. 29. Kengne AP, Fezeu L, Sobngwi E, Awah PK, Aspray TJ, Unwin NC, et al. Type 2 diabetes management in nurse-led primary healthcare settings in urban and rural Cameroon. Primary Care Diabetes. 2009;3(3):181-8. 30. Brownie S, editor Opportunities for the development of nurse-led services for the management of preventable illness & chronic disease in the UAE. Al Gharbria 2nd International Nursing Conference; 2013; Abu Dhabi, UAE. 31. Mccallin A. Interdisciplinary practice – a matter of teamwork: an integrated literature review. Journal of Clinical Nursing. 2001;10(4):419- 28. 32. Jessup RL. Interdisciplinary versus multidisciplinary care teams: do we understand the difference? Australian Health Review. 2007;31(3):330. 33. Norrefalk J-R. How do we define multidisciplinary rehabilitation? Journal of Rehabilitation Medicine. 2003;35(2):100-1. 34. McGill M, Felton A-M. New global recommendations: A multidisciplinary approach to improving outcomes in diabetes. Primary Care Diabetes. 2007;1(1):49-55. 35. Mesmer-Magnus JR, DeChurch LA. Information sharing and team performance: A meta-analysis. Journal of Applied Psychology. 2009;94(2):535-46. 36. Organization WH. Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines. 2007.

55 REFERENCES

37. Maier CB, Aiken LH. Task shifting from physicians to nurses in primary care in 39 countries: a cross-country comparative study. European Journal of Public Health. 2016;26(6):927-34. 38. Altschuler J, Margolius D, Bodenheimer T, Grumbach K. Estimating a reasonable patient panel size for primary care physicians with team-based task delegation. The Annals of Family Medicine. 2012;10(5):396-400. 39. Data Mapping. Oman Population (Demographics, Maps, Graphs) 2018 [2018, June 8]. Available from: worldpopulationreview.com/countries/oman-population. 40. Geography Statistics Of Oman 2018 [cited 2018 November, 2018]. Available from: https://www.worldatlas.com/webimage/countrys/asia/oman/omlandst.ht m - page. 41. Oman Demographics Profile 2018 [2018, June 8]. Available from: https://www.indexmundi.com/oman/demographics_profile.html. 42. Oman-Literacy rate 2018 [cited 2018 November, 2018]. Available from: https://www.indexmundi.com/facts/oman/literacy-rate. 43. Oman GDP 2018 [cited 2018 November, 2018]. Available from: https://tradingeconomics.com/oman/gdp. 44. WHO. Oman: WHO statistical profile 2014 [cited 2018 September, 2018]. Available from: http://www.who.int/countries/omn/en/. 45. Oman-Religion 2018 [cited 2018 November, 2018]. Available from: https://www.globalsecurity.org/military/world/gulf/oman-religion.htm. 46. Climate of the World: Oman | weatheronline.co.uk 2018 [cited 2018 2018, June 8]. Available from: https://www.weatheronline.co.uk/reports/climate/Oman.htm. 47. Al-Dhali HNH. Prevalence of Obesity and its Association with Diet among 13-years Old Omani School Children. Canadian Journal of Clinical Nutrition. 2016. 48. Musaiger AO, Ahmed MA, Rao MV. Chemical composition of some traditional dishes of Oman. Food Chemistry. 1998;61(1):17-22. 49. Kilani H, Al-Hazzaa H, Waly MI, Musaiger A. Lifestyle Habits: Diet, physical activity and sleep duration among Omani adolescents. Sultan Qaboos University Medical Journal. 2013;13(4):510-9. 50. Malpass A, Andrews R, Turner KM. Patients with type 2 diabetes experiences of making multiple lifestyle changes: a qualitative study. Patient education and counseling. 2009;74(2):258-63.

56 REFERENCES

51. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care. The Lancet. 2003;362(9391):1225-30. 52. Al-Moosa S, Allin S, Jemiai N, Al-Lawati J, Mossialos E. Diabetes and urbanization in the Omani population: an analysis of national survey data. Population Health Metrics. 2006;4(1):5. 53. Al Riyami A, Afifi M. Smoking in Oman: prevalence and characteristics of smokers. 2004. 54. Al-Lawati JA, Muula AS, Hilmi SA, Rudatsikira E. Prevalence and Determinants of Waterpipe Tobacco Use among Adolescents in Oman. Sultan Qaboos University medical journal. 2008;8(1):37-43. 55. Al-Hazzaa HM, Musaiger AO, Group AR. Arab Teens Lifestyle Study (ATLS): objectives, design, methodology and implications. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 2011;4:417-26. 56. Al-Kilani H, Waly M, Yousef R. Trends of Obesity and Overweight among College Students in Oman: A cross sectional study. Sultan Qaboos University Medical Journal. 2012;12(1):69-76. 57. Al Barwani S, Al Abri M, Al Hashmi K, Al Shukeiry M, Tahlilkar K, Al Zuheibi T, et al. Assessment of aerobic fitness and its correlates in Omani adolescents using the 20-metre shuttle run test: A pilot study. Journal for scientific research Medical sciences / Sultan Qaboos University. 2001;3(2):77-80. 58. Al-Lawati JA, Mabry R, Mohammed AJ. Addressing the threat of chronic diseases in Oman. Preventing chronic disease. 2008;5(3):A99-A. 59. Al Riyami A, Elaty MAA, Morsi M, Al Kharusi H, Al Shukaily W, Jaju S. Oman world health survey: part 1-methodology, sociodemographic profile and epidemiology of non-communicable diseases in oman. Oman medical journal. 2012;27(5). 60. Al-Lawati JA, Panduranga P, Al-Shaikh HA, Morsi M, Mohsin N, Khandekar RB, et al. Epidemiology of Diabetes Mellitus in Oman: Results from two decades of research. Sultan Qaboos University medical journal. 2015;15(2):e226-33. 61. Al-Moosa S, Allin S, Jemiai N, Al-Lawati J, Mossialos E. Diabetes and urbanization in the Omani population: an analysis of national survey data. Population health metrics. 2006;4:5. 62. Al-Lawati JA, Mabry R, Mohammed AJ. Addressing the threat of chronic diseases in Oman. Prev Chronic Dis. 2008;5(3):A99.

57 REFERENCES

63. Al-Shookri A, Khor GL, Chan YM, Loke SC, Al-Maskari M. Type 2 diabetes in the sultanate of Oman. Malaysian journal of nutrition. 2011;17(1):129-41. 64. Al-Lawati JA, Barakat MN, Al-Maskari M, Elsayed MK, Al-Lawati AM, Mohammed AJ. HbA1c Levels among Primary Healthcare Patients with Type 2 Diabetes Mellitus in Oman. Oman medical journal. 2012;27(6):465- 70. 65. MOH. Health Sector Complementary Study (HSCS) for Health Professions Education in University of Oman. Oman: MOH; May, 2013. 66. Alshishtawy MM. Four Decades of Progress: Evolution of the health system in Oman. Sultan Qaboos University medical journal. 2010;10(1):12-22. 67. Health Mo. Glimpses of Statistics 2017. Department of Information and Statistics: Directorate General of Planning and Studies; 2017. 68. MOH. Diabetes Mellitus Management Guidelines. Oman: The National Diabetes and Endocrine Centre; 2015. 69. Lemieux-Charles L, McGuire WL. What Do We Know about Health Care Team Effectiveness? A Review of the Literature. Medical Care Research and Review. 2006;63(3):263-300. 70. Abdulhadi N, Al-Shafaee MA, Östenson C-G, Vernby Å, Wahlström R. Quality of interaction between primary health-care providers and patients with type 2 diabetes in Muscat, Oman: an observational study. BMC family practice. 2006;7(1):72. 71. Abdulhadi N, Al Shafaee M, Freudenthal S, Östenson C-G, Wahlström R. Patient-provider interaction from the perspectives of type 2 diabetes patients in Muscat, Oman: a qualitative study. BMC health services research. 2007;7(1):162. 72. Alyaarubi S. Diabetes Care in Oman: Obstacles and solutions. Sultan Qaboos University medical journal. 2011;11(3):343-8. 73. Cooper J, Lewis R, Urquhart C. Using participant or non-participant observation to explain information behaviour. Information Research-an International Electronic Journal. 2004;9(4):9-4. 74. Brinkmann S. Interview. Encyclopedia of critical psychology: Springer; 2014. p. 1008-10. 75. Ministry of Health. Annual Health Report. Muscat; 2016. 76. Fink A. How to conduct surveys: A step-by-step guide: Sage Publications; 2015.

58 REFERENCES

77. Carolyn Lees R. Measuring the patient experience. Nurse Researcher (through 2013). 2011;19(1):25. 78. Fylan F. Semi-structured interviewing. A handbook of research methods for clinical and health psychology. 2005:65-78. 79. Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nursing & health sciences. 2013;15(3):398-405. 80. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology. 2006;3(2):77-101. 81. Smith JA. Qualitative psychology: A practical guide to research methods: Sage; 2015. 82. WHO. Noncommunicable Disease Progress Monitor. 2017. 83. MOH. Strategic Research Programme for Non-Communicable Diseases. Oman; 2018. 84. Bodenheimer T, MacGregor K, Stothart N. Nurses as leaders in chronic care. BMJ. 2005;330(7492):612-3. 85. Khoja T, Rawaf S, Qidwai W, Rawaf D, Nanji K, Hamad A. Health care in Gulf Cooperation Council countries: a review of challenges and opportunities. Cureus. 2017;9(8). 86. Alwin Robert A, Abdulaziz Al Dawish M, Braham R, Ali Musallam M, Abdullah Al Hayek A, Hazza Al Kahtany N. Type 2 diabetes mellitus in Saudi Arabia: major challenges and possible solutions. Current diabetes reviews. 2017;13(1):59-64. 87. Garber A, Abrahamson M, Barzilay J, Blonde L, Bloomgarden Z, Bush M, et al. AACE Comprehensive Diabetes Management Algorithm 2013. Endocrine Practice. 2013;19(2):327-36. 88. Al-Lawati JA, Al Riyami AM, Mohammed AJ, Jousilahti P. Increasing prevalence of diabetes mellitus in Oman. Diabet Med. 2002;19. 89. Del Prato S, Felton A-M, Munro N, Nesto R, Zimmet P, Zinman B. Improving glucose management: Ten steps to get more patients with type 2 diabetes to glycaemic goal. International Journal of Clinical Practice. 2005;59(11):1345-55. 90. Harris MF, Zwar NA. Care of patients with chronic disease: the challenge for general practice. Medical Journal of Australia. 2007;187(2):104-7.

59 REFERENCES

91. Corrigan JM. Crossing the quality chasm. 2005 [cited December 12, 2019]. In: Building a better delivery system: A New Engineering/Health Care Partnership [Internet]. USA: Institute of Medicine, National Academy of Engineering, [cited December 12, 2019]. 92. Klautzer L, Becker J, Mattke S. The curse of wealth–Middle Eastern countries need to address the rapidly rising burden of diabetes. International journal of health policy and management. 2014;2(3):109. 93. Sebire SJ, Toumpakari Z, Turner KM, Cooper AR, Page AS, Malpass A, et al. “I’ve made this my lifestyle now”: a prospective qualitative study of motivation for lifestyle change among people with newly diagnosed type two diabetes mellitus. BMC Public Health. 2018;18(1):204. 94. Salas E, Almeida SA, Salisbury M, King H, Lazzara EH, Lyons R, et al. What Are the Critical Success Factors for Team Training in Health Care? The Joint Commission Journal on Quality and Patient Safety. 2009;35(8):398-405. 95. Bowen A. Factors Leading to Motivational Decline among Team Members and the Impact of Motivational Decline on Project Success: Northcentral University; 2016. 96. Johnson J, Carragher R. Interprofessional collaboration and the care and management of type 2 diabetic patients in the Middle East: A systematic review. Journal of interprofessional care. 2018;32(5):621-8. 97. Spence Laschinger HK, Finegan J, Shamian J. The impact of workplace empowerment, organizational trust on staff nurses' work satisfaction and organizational commitment. Advances in Health Care Management: Emerald Group Publishing Limited; 2002. p. 59-85. 98. Choi J-Y, Kim E-K, Kim SY. Effects of Empowerment and Job Satisfaction on Nursing Performance of Clinical Nurses. J Korean Acad Nurs Adm. 2014;20(4):426-36. 99. van Dam HA, Van der Horst F, Van den Borne B, Ryckman R, Crebolder H. Provider–patient interaction in diabetes care: effects on patient self-care and outcomes: a systematic review. Patient education and counseling. 2003;51(1):17-28. 100. Schadewaldt V, Schultz T. Nurse-led clinics as an effective service for cardiac patients: results from a systematic review. International Journal of Evidence-Based Healthcare. 2011;9(3):199-214.

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Department of Epidemiology and Global Health Umeå University, SE-901 87 Umeå, Sweden www.umu.se/en/department-of-epidemiology-and-global-health/

ISBN 978-91-7855-042-5 ISSN 0346-6612