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Process evaluation of integrated diabetes management at primary healthcare facilities in Pakistan: a mixed-methods study

Muhammad Amir Khan, John D Walley, Saima Ali, Rebecca King, Shaheer Ellahi Khan, Nida Khan, Faisal Imtiaz Sheikh and Haroon Jehangir Khan
BJGP Open 2018; 2 (4): bjgpopen18X101612. DOI: https://doi.org/10.3399/bjgpopen18X101612
Muhammad Amir Khan
1 Chief Coordinating Professional, Association for Social Development, , Pakistan
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John D Walley
2 Professor of International Public Health, Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, , UK
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Saima Ali
3 Research Coordinator, Association for Social Development, , Pakistan
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Rebecca King
4 Lecturer, Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, , UK
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Shaheer Ellahi Khan
5 Assistant Professor, Humanities and Social Sciences Department, Bahria University, , Pakistan
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Nida Khan
6 Project Coordinator, Association for Social Development, , Pakistan
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  • For correspondence: nidakhan@asd.com.pk
Faisal Imtiaz Sheikh
7 Research Coordinator, Association for Social Development, , Pakistan
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Haroon Jehangir Khan
8 Director, NCD & Mental Health, Directorate General of Health Services, , Pakistan
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Article Figures & Data

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  • Figure 1
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    Figure 1 Sampling for interviews. RHC = rural health centre. THQ = Tehsil headquarters.
  • Figure 2
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    Figure 2 Patient attrition in intervention and control arms

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    Box 1. Selected care tasks and key indicators
    Care taskKey indicators
    QuantitativeQualitative
    Screening and diagnosis1. Number of patients with diabetes registered, as percentage of overall outpatient attendance2. Number and percentage of patients examined for baseline clinical and laboratory, and age/anthropometric measurementsPatient’s and provider’s experiences, as well as practice deviations and reasons for:
    • identifying and examining patients who are overweight or symptomatic of diabetes mellitus

    • conducting clinical and laboratory exams, and diagnosis

    Prescriptions3. Number and percentage of patients prescribed as per guidelines for diabetes and/or hypertension:
    • without comorbid condition

    • with comorbid condition (renal insufficiency; pregnancy)

    4. Number and percentage of uncomplicated patients prescribed drugs without trying a lifestyle change 5. Number and percentage of patients prescribed preventive treatment
    Patient’s and provider’s experiences, as well as practice deviations and reasons for:
    • prescribing, as per guide

    • trialling lifestyle changes before drugs

    • prescribing preventive drugs

    Lifestyle modification6. Recording of smoking status and staff responsePatient’s and provider’s experiences, as well as practice deviations and reasons for:
    • counselling patient (with pictorial tool) for lifestyle change and smoking cessation

    • estimating and use of 'target weight' for patient counselling

    Follow-up and adherence7. Number and percentage of patients adhering to follow-up visits (in first 9 months) 8. Number and percentage of patients examined (clinical/ laboratory) on follow-up visits 9. Number and percentage of patients referred for expert check-up and/or complication and/or severe drug reactionPatient’s and provider’s experiences, as well as practice deviations and reasons for:
    • patient adherence to follow-up visits (include retrieval)

    • staff adherence to care during follow-up visit

    • referrals (for example, side effects)

    Material inputsPatient’s and provider’s experiences, as well as practice deviations and reasons for:
    • maintaining uninterrupted inputs

    • coping with input gaps and/or challenges

    • View popup
    Box 2. Logic model for the intervention
    Intervention inputsIntervention process and actionsIntended
    Practice changeOutputsHealth outcome
    • Case management desk guide and lifestyle counselling tool

    • Training of doctors and allied staff (on full care package)

    • Supplement drugs, equipment and supplies (digital blood pressure apparatus, glucometer, and strips)a

    • Recording formsa

    • Screen/diagnosea

    • Prescribe anti-diabetic drugs

    • Identify co-morbid condition and treat

    • Counsel for lifestyle modification

    • Follow-up care, including retrieval

    Providers practise programme protocols to:
    • Screen, diagnose, treat, counsel, follow-up, and report as per programme protocol

    Patients practise:
    • Follow-up visits

    • Treatment

    • Lifestyle changes (as counselled)

    Patients gets:
    1. Screened and diagnosed as per programme protocol

    2. Prescribed right drug/ dose

    3. Counselled for lifestyle change

    4. Followed-up and treated for continued care

    • Reduction (0.5%) in mean HbA1c

    • Increased proportion achieving HbA1c <7%.

    • Reduction in complications related to diabetes

    • aInputs/ practices kept same in intervention and control arms.

    • View popup
    Table 1. Prescriptions for diabetes
    ArmTreatment without associated proteinuriaTreatment with associated proteinuria
    Biguanide OthersTotalSulphonylurea OthersTotal
    n%n%n%n%n%n%
    Intervention14163.28236.82231001453.81246.226100
    Control9142.512357.5214100723.32376.730100
    Total23253.120546.94371002137.53562.556100
    • View popup
    Table 2. Preventive medication
    ArmEligibleTreated
    Raised blood pressureSmokersTotaln%
    Intervention60379755.1
    Control6828961313.5
    Total12865193189.3
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Process evaluation of integrated diabetes management at primary healthcare facilities in Pakistan: a mixed-methods study
Muhammad Amir Khan, John D Walley, Saima Ali, Rebecca King, Shaheer Ellahi Khan, Nida Khan, Faisal Imtiaz Sheikh, Haroon Jehangir Khan
BJGP Open 2018; 2 (4): bjgpopen18X101612. DOI: 10.3399/bjgpopen18X101612

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Process evaluation of integrated diabetes management at primary healthcare facilities in Pakistan: a mixed-methods study
Muhammad Amir Khan, John D Walley, Saima Ali, Rebecca King, Shaheer Ellahi Khan, Nida Khan, Faisal Imtiaz Sheikh, Haroon Jehangir Khan
BJGP Open 2018; 2 (4): bjgpopen18X101612. DOI: 10.3399/bjgpopen18X101612
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More in this TOC Section

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