Background
Methods
Objective
Study setting
Study design
Epidemiology of clinic population: general chart review
Current practice and quality of care: focused chart review
Provider practice pattern and perspectives: online survey
Patient perspectives: Structured interviews and questionnaire
Data analysis
Results
Epidemiology of clinic population: General chart reviews
Chart review | I | II |
---|---|---|
Demographic |
n = 60 |
n = 60 |
Female – % (n = 60) | 62 | 75 |
Age – yrs (n = 60) | 44 ± 17 | 42 ± 15 |
Ethnicity – % | (n = 52) | (n = 60) |
Maya | 64 | 70 |
Garifuna | 4 | 8 |
East Asian/Indo-carribean | 17 | 2 |
Creole/Afro-caribbean | 2 | 0 |
Mestizo | 0 | 3 |
White | 0 | 0 |
Other | 13 | 18 |
Clinic visits per year – visits (n = 60) | 2.1 ± 2 | 1.9 ± 2.7 |
Chronic disease – % (n = 60)a
| ||
Diabetes | 12 | 13 |
Hypertension | 12 | 13 |
Current practice and quality of care: Focused chart review
Chart review III | ||
---|---|---|
Demographic data | Diabetes | Hypertension |
n = 112 |
n = 110 | |
Female | 74% | 73% |
Age – yrs | 52 ± 14 | 59 ± 14 |
Ethnicity | ||
East Asian/Indo-carribean | 22% | 32% |
Garifuna | 10% | 16% |
Mayan | 41% | 12% |
Creole/Afro-caribbean | 7% | 11% |
Mestizo | 3% | 4% |
White | 3% | 4% |
Other | 24% | 21% |
Clinic visits per year – visits | 3.4 ± 4 | 4.1 ± 4.2 |
Chart review III | |
---|---|
Diabetic patients (at least one clinic visit within the past 12 months) | |
Diabetic management |
n = 83 |
Number of oral diabetic medicationsa – Num | 1.3 ± .7 |
Patients on insulin therapy | 10% |
Foot exam in past 12months | 41% |
Eye referral in past 12months | 41% |
Serum creatinine in past 12months | 39% |
Urinalysis in past 12months | 28% |
Lipid panel ever preformed | 67% |
Dietary counseling | 60% |
Diabetic controlb
|
n = 80 |
Average fasting blood sugarb (N = 40) | 201 ± 81 |
Average random blood sugarb (N = 40) | 255 ± 139 |
Diabetics with last BS > 300 - % (n = 80) | 18% |
Diabetics with last BS > 400 - % (n = 80) | 10% |
Diabetics with last BS > 500 - % (n = 80) | 4% |
Diabetics at goalc - % (n = 80) | 26% |
Chart review III | |
---|---|
Diabetic management |
N = 59 |
Patients on no diabetic therapy | 7% |
Patients on only one oral medicationb
| 34% |
Patient on two oral agentsb
| 49% |
Patients on NPH insulin therapy | 10% |
Diabetic control | |
Average fasting blood glucose (FBG)c
| 219 ± 74 |
Average random blood glucose (RBG)c
| 333 ± 118 |
Chart review III | |
---|---|
Hypertension (clinic visit in past 12 months) | Total n = 85 |
Antihypertensive medicationsa – num (n = 97) | 1.3 ± .9 |
Patients at blood pressure goalb – % (n = 80) | 51 |
Lifestyle counseling documentedc – % | 60 |
Patients with related end organ diseased – % | 27 |
Stakeholder perspective: Provider perceptions of care
Provider demographics (n = 20) | |
---|---|
Type of provider - % (n = 20) | |
Physician (MD/DO, internist, pediatrician, family practitioner) | 80% |
RN/RNP | 10% |
Physician Assistant | 5% |
Pharmacist | 5% |
Typical practice setting - | |
Outpatient/Clinic | 40% |
Inpatient | 30% |
Emergency/Urgent Care | 5% |
Other | 30% |
Primary patient population | |
Urban/suburban | 80% |
Rural | 15% |
Migrant | 5% |
Country provider trained | |
Australia | 5% |
UK | 10% |
Guatemala | 5% |
USA | 80% |
Provider perceived barriers to appropriate care of diabetes, including insulin use |
---|
• “When it [insulin] has been there in the past the barriers include lack of refrigeration.” |
• “In the villages there is no fridge, and no test strips, making monitoring difficult.” |
• “There is a lack of blood glucose monitoring – even if a patient is newly starting insulin or very unwell they may get 5 test strips for the first week. For longer term patient they get 1 strip per month!” |
• “I regularly encountered poor understanding from patients, and conflicting health beliefs which lead to poor compliance.” |
Stakeholder perspectives: Patients’ understanding of disease
General health and risk factors
Demographic | Total n = 25 |
---|---|
Female – % (n = 25) | 72 |
Age – yrs (n = 25) | 59 ± 19 |
Ethnicity – % (n = 25) | |
Maya | 28 |
Garifuna | 20 |
East Asian/Indo-carribean | 12 |
Creole/Afro-caribbean | 8 |
Mestizo | 8 |
White | 0 |
Other | 24 |
Home amenities – % (n = 25) | |
Electricity | 80 |
Running water | 72 |
Primary school education – % (n = 25) | 84 |
Employment – % (n = 25) | |
Unemployed / retired | 40 |
Homemaker | 36 |
Full time | 16 |
Part time | 8 |
Tobacco use – % (n = 25) | 4 |
Alcohol use – % (n = 25 | 16 |
Chronic disease – % (n = 25) | |
Diabetes | 76 |
Hypertension | 56 |
Understanding of health, diabetes, and hypertension
Individuals’ understanding of health, diabetes, and hypertension |
---|
• “To be healthy is to be perfect – no problems. But we can make ourselves healthy. It depends on what we put in our mouth.” –38 y/o F, mixed ethnicity |
• “The environment causes sickness.” -40 y/o M, East Indian |
• “It [sickness] is from the air. There are too many pollutions – not like before. But because of that same thing the drinking water is not proper. So they improve it a lot by putting that pump by the side of the road.” -43 y/o F, mixed ethnicity |
• Sickness is caused by “what we eat and what we drink. Too much salt. Too much sweet.” -38 y/o F, mixed ethnicity |
• “When I cry and cry and cry, then I eat and eat and eat – that’s why I catch the sickness.” -44 y/o F, Q’eqchi' Mayan |
• “I have a son that drowned. I said to myself I was not worrying but it was still in my mind. So from there, I have pressure.” – 64 y/o F, Garifuna |
How individuals with diabetes and/or hypertension manage their disease |
---|
• “We have to control ourselves for what we eat or drink. With the medication, it helps.” – 53 y/o F, mixed ethnicity |
• “Exercise most importantly. Take my medication. Do not eat starchy foot! Mostly vegetables. But it is hard to eat veg everyday.” – 38 y/o F, mixed ethnicity |
• “I do not eat much salt or lard. I do not drink any coffee.” – 31 y/o F, Q’eqchi' Mayan |
• “You have to eat less salt. The thing that you eat – especially when you buy at the shop. It has salt. Like pig tail. It has a lot of salt. I eat it only once a week.” – 59 y/o M, Garifuna |
• “I do not drink sugar. I stop drinking coffee. I eat meat. Not fats. I try herbs. I try the bitter one – I do not know which one. It works. I drink at morning, midday, and in the evening. I also drink the noni fruit. Raw onion – it is good for high cholesterol. I also eat garlic. I eat raw garlic.” – 41 y/o F, Q’eqchi' Mayan |
How knowledge about disease and self-management is attained
Barriers to care
“You see what happen in this part of the country – we eat what we can afford. Sometimes you can afford to buy things for the sugar but not all the time. You have to eat what you found. Vegetables are very expensive. You have a time when you cannot buy any vegetables. So you have to find rice or something. People eat what they find. It is not because they want to eat it, but they have to eat. If you don’t eat, you might get sick. You can die! Things are expensive!”