From: Challenges of managing diabetes in Iran: meta-synthesis of qualitative studies
WHO components of health systems | Original sub-themes extracted from studies | Studied themes | |
---|---|---|---|
Major themes | Major themes | ||
Holistic understanding of patients in his/her environment | - Insufficient attention/training from the therapeutic team [24] - Lack of time spent with clients by physicians [21] - Lack of belief among patients in services provided by general practitioners (first level) [23]. - Lack of physicians’ success in earning patients trust [22] - Mistrust of health care providers’ advice [21] - Lack of mutual understanding about patient situation between patients and family members [24] - Being ignored by family members [20] - Lack of support from family [20] - Medically inappropriate expectations of relatives (e.g. To eat more with them) [21] - Patients feel embarrassed injecting insulin in public [21] - Insufficient awareness of public regarding the diabetes [21, 27] - Lack of appropriate programs in media [21] - Lack of free exercise facilities at public parks could be an asset [21] - High living costs resulted in stresses that did not allow diabetes to be as a priority [21]. - Weak organization and performance of NGOs [27] | Holistic understanding of patients in his/her environment | - Insufficient attention to patients - Lack of patients trusts in healthcare and healthcare providers - Insufficient family support - Insufficient community support |
Leadership and governance | - Ineffective inter-sectoral coordination (e.g. Health and treatment deputy [23] - Lack of integrated care [23] - Low cooperation of other service providers [27] - Ineffective healthcare systems [17] - Physical separation of first and second level health centers [27] - Incompliance of health network with non-communicable diseases [27] - Weak performance evaluation [27] - Lack of continuous supervision on evidence based instruction performance [25] | Leadership and governance | - Ineffective care coordination - Weak performance evaluation |
Service delivery | - Insufficient facilities [24] such as shortage of specialists centers [24] diabetic foot management canters [27] - Lack of support in terms of access to services [21] - Unavailability of drugs [19] - There are no local services [21] - Insufficient laboratory services for thesecond level patients [27] - Unavailability of services [28] - Lack of care at hospital despite timely hospitalization [24] - Long hospital waiting times [24]. - Difficulties in receiving service from public centers [27] and unsuitable working hours [27] - Overcrowded hospitals and outpatient clinics [23] - Problems accessing modern treatments and technologies [21] - Inadequate packages and guidelines [23, 28] - And specialized protocols [23] - No need-based organization chart [25] - Unsuitable health care services for diabetic patients [28] - Patients ignore self-care [26] and have low motivation in this regards [27] - Patients do not consider diabetes as a serious health threat [26] - Patients are not committed to visit the physician regularly [18, 25] and timely [24], to follow ordered nutrition and drug use and regular exercise [18, 24, 25] - Lack of self-efficacy to change lifestyle [21] and difficulties in integrating treatment with daily activities [26] - They avoid to take insulin because they considered insulin consumption as a symptom of their disease deterioration [24] - Most patients did not do regular tests for controlling their blood sugar level [24] - Lower priority of diabetes management compared to other needs (e.g. Children need) [21] - Patient education/training is inadequate [18, 21, 24] - Patients’ poor knowledge and skill regarding the disease [26] - Lack of resources to educate patients [21] - Patients are not committed to participate in group training courses [25] - Misconceptions about diabetes among patients [20] - Patients are unaware of their disease up to appearance of an ulcer [24] - Insufficient information about their nutritious diet [24] and the normal level of blood sugar [24]. - Incomplete information about alternative therapies [21] - Self-medication [19, 20, 24] - Voluntary disorganization of drug use consumption based on self-perception [20] - Negative perceptions of Iranian medicines [21] - Lack of effective follow up system [18, 23,24,25, 27], especially in elderly patients [27] - Passive referral and lack of coordination in referral [27]. - Low motivation of first level physicians [27]/ High turnover of first level physicians [27] | Service delivery | - Self-management problems:  ➢ Lack of patients commitments  ➢ Insufficient patients knowledge/training/ skill  ➢ Self-medication - Access difficulties - Shortage of diabetes specific facilities - Weak referral system - Inadequate treatment guidelines |
Workforce | - Shortage of human resources [24, 27] such as nutritionists [18], nursing [23] - Inadequate knowledge of physicians [22] - Lack of continuous primary training among physicians [22] - Inadequate supervision on physician training process [22] - Lack of integrated education system [27] - Limited interaction among physician and nurses [18] - Lack of shared discussion among the specialists about the curing approach [24] - Lack of physicians’ success in earning colleagues’ trust [22] | Workforce | - Workforce shortage - Insufficient knowledge/training - Weak teamwork |
Financing | - Insufficient insurance coverage of first level services [27] - Insurance coverage is not adequate (lack of coverage for blood glucose test strips, glucometers) [21] - Unaffordability of some medicines [27] - Lack of support in terms of cost [21] | Financing | - Insufficient insurance coverage |
Information and research | - Not recording the visit date or the test results [18] - Defective records registration [25] - Information system failure [27] - Inactive information dissemination [23] | Information and research | - Weak information technology |
Technologies and medical products | – | – | – |