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| Journal of the New Zealand Medical Association,
14-March-2008, Vol 121 No 1270
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Concordance and discordance between primary and
secondary care health workers in perceptions of barriers to diabetes
care
Steven Lillis, Judith Swan, Jarrod Haar, David Simmons
Three factors interact to contribute to the outcomes of
management in diabetes: the health care provider, the patient, and the health
care system. Well-organised systems of care for chronic disease states are known
to substantially improve outcomes in diabetes.1
This beneficial influence is true for both secondary and primary
care.2
Knowledge of, and agreement with, evidence-based guidelines
also positively influences practice.3 As would
be expected, the knowledge of specialists in their area of expertise exceeds
that of generalists and their use of ‘best practice’ interventions
is higher.4 General practitioners and practice
nurses, on the other hand, are in an environment characterised by ‘high
uncertainty-low technology’ where multiple imperatives (such as
comorbidities, social dysfunction, poverty, and preventative health initiatives)
compete for attention. Patterns of disease burden, disease complexity,
comorbidity, outcome, and resource utilisation have been shown to differ between
secondary care and primary care in diabetes.5
The experiences of those working in secondary care and
primary care are clearly different. It is probable, therefore, that there are
also differences in perception as to what barriers exist in achieving good
diabetes care and how important these barriers are. This research explores areas
of commonality and difference between two groups of health care workers in the
same region: those involved in primary care and those involved in secondary care
in the Waikato region of New Zealand.
MethodsStudy design—The dataset
utilised was the Barriers to Diabetes Care in the Waikato study. In
2003 a total of 232 general practitioners and 220 practice nurses from the
Midland region of New Zealand were invited to participate in a postal survey.
The Dillman method (study information and questionnaire in stamped, addressed
envelopes with repeat request for non responders) was used to maximise
returns.7
Replies were received from 166 general practitioners
(72%) and 149 practice nurses (68%). A total of 173 hospital health care workers
in the Midland region were invited to participate. Replies were received from
123 staff (71%) including doctors, nurses, and dieticians thus giving an overall
response rate of 69%.
The respondents were asked for demographic data and
their responses to these 5 questions:
A validated coding system
previously reported was used to code all
replies.8 The coding system allows analysis of
statements by allocating the statements to one of five broad categories:
psychological, educational, internal physical, external physical (including
administrative barriers), and psychosocial. As can be seen in Table 1, more
detailed codes were available with each broad category. All statements were
collated, reviewed, and separately coded by at least two of the researchers.
Disagreements in coding were resolved by discussion.
Statistics—Data were analysed
using SPSS for Windows (v14.0) software. The Z test of proportionality was used
to analyse for significance as it was desired to compare the proportion of two
different populations who responded in a similar way to the study questions. A
sample of 50 random responses were recoded blind to the original codes to assess
reproducibility of the coding process. A kappa coefficient of 0.68 was achieved
on comparison of original coding and re-coding. This would indicate a
satisfactory level of agreement.9
ResultsAn overall response rate of 69% was obtained in this survey.
A total of 4888 statements were available for coding: 3297 from primary care and
1591 from secondary care. A comparison of the proportion of statements by
barrier code between primary care health workers and secondary care health
workers appears in Table 2.
Areas of commonality between the two groups included the
code “unsatisfactory/inappropriate diabetes care or education” (code
22) as the second most commonly reported barrier to good care in both
professional groups. The three prominent and inter-related barriers of
motivation, lifestyle change, and self efficacy (codes 4, 5, and 30
respectively) were ranked highly by both groups and will be discussed further.
Codes where secondary health care workers responses were
significantly greater than primary care workers are given in Table 3 and
indicate that secondary care workers are distinct from their primary care
colleagues in reporting barriers of staffing levels, appointment systems,
inappropriate cultural messages, insufficient community based care, overwhelming
workload, and previous unsatisfactory interactions with health
professionals.
Table 1. Barriers to diabetes care coding
framework
Table 2. Percentage of statements by
code
*p <0.05; **p <0.01; ***p <0.001; ns=not
significant.
Table 3. Barriers to diabetes care where
secondary care perception of barrier was greater than primary
care
Codes where primary health care workers gave significantly
more responses than secondary are given in Table 4. Primary care providers
perceived motivation (code 4), self efficacy (code 5), personal finance (code 8)
and public health belief (code 6) as barriers more often than secondary care
providers.
Table 4. Barriers to diabetes care where
primary care workers perception of barrier was greater than secondary
care
A more detailed analysis of statements concerning staff
levels and appointment system (Code 13) by secondary care participants revealed
that 52% of statements related to inadequate staffing levels in the hospital,
27% to poor systems of organisation to provide appointments, and the remainder
(21%) reflected access difficulties to primary care appointments.
DiscussionShared concerns—The response rate is
unusually high for surveys10 and may indicate a
significant level of concern over diabetes care by health workers in general as
well as the effectiveness of the Dillman system for increasing the response rate
from surveys.11
The data indicates particular areas of concern to both
primary and secondary health workers highlighting patient education and
psychological barriers such as motivation as principal foci. Current
interventions would seem not to impact adequately on these barriers. Indeed, it
may be unrealistic to expect episodic interventions from health professionals to
provide high levels of motivation when there are multiple agendas to cover in a
brief consultation for a disease characterised by complexity and comorbidity.
Diabetes prevention and treatment in a social rather then
medical construct facilitates the evolution of different
solutions.12 Developing the motivation, social
support systems, and self-belief to negotiate the lifestyle changes and
restraints imposed by diabetes fits more comfortably into a social rather than
medical agenda.
Successfully meeting this social agenda may require
reconsideration of the ‘ownership’ of diabetes and the
‘responsibility’ for diabetes management; is it a disease that is
diagnosed and treated by health professionals or is it a reflection of modern
society? Quoting Chaufan on the sociology of diabetes: Attempts, however
well intentioned, to empower patients to choose
a style of diabetes care that fits their needs or to fight
for their rights and freedoms are problematic
if choices and freedom are seriously limited by
social and structural conditions and if this
limitation is ignored.13 If indeed,
diabetes is fundamentally a sociological problem, it is likely that the best
long-term solutions are sociological rather than medical in
nature.14
Predominant secondary care
perceptions—There was clear discordance between primary and
secondary care practitioners regarding staffing levels and appointment systems.
These barriers were the most commonly noted barrier to diabetes care by hospital
respondents, yet were ranked only 12th by
primary care participants. Related to the staffing level and appointment
statements by secondary care workers is the high number of statements regarding
the epidemic of diabetes and the lack of community-based services.
It is likely that such statements reflect the tension
created when demand for services significantly outstrips capacity, coupled with
the belief that some of these services would be better provided in a community
rather than a hospital setting. Similarly, concerns over health care education
of those with diabetes may reflect inadequate capacity to deliver effective
diabetes education.
Cultural concerns were significantly greater in the
secondary care group. This may be explained by the selected nature of those
attending secondary care for diabetes treatment. Prevalence, morbidity and
mortality rates are higher for Māori than New Zealanders of European
descent for diabetes including higher admission rates to
hospital.15 Thus hospital health care workers
have higher exposure to Māori who live with diabetes. An alternative
explanation is that hospital-based health care workers are more culturally aware
than those in primary care.
Predominant primary care
perceptions—A notable factor in statements made from primary care
is that financial issues were more commonly seen as barriers than is the case
with hospital-based participants. These financial difficulties concerned both
lack of government funding for diabetes care as well as personal financial
barriers. Patient fees for primary care consultations as well as the more
visible costs of medication in community-based care may be partly responsible
for this.
Comparative studies—These findings
accord well with other studies. A qualitative study that explored the
experiences of 31 primary care physicians in America revealed that diabetes was
considered particularly difficult to manage in comparison to other chronic
diseases.16 The authors highlighted the
inability to influence lifestyle factors, the asymptomatic nature of early
disease, the expense of care and discrepancy between provider and patient sense
of urgency in treatment as significant difficulties.
Lack of patient motivation was considered to be a major
barrier to good diabetes care in a Belgian study of general
practitioners.17 A Canadian study further
emphasised psychological factors including denial and lack of motivation as well
as financial cost of diabetes to the patient as barriers to management of the
disease.18 Low levels of agreement have been
found between patients and general practitioners regarding priorities of
treatment in Type 2 diabetes, a factor that increases provider
frustration.19
A multinational study of patients and their providers
(nurse, primary care physician and secondary care physician) reported that
61–72% of providers recognised psychological problems in their Type 2
diabetic patients but also reported being more able to recognise than meet these
psychological needs.20
ConclusionsThe steadily increasing disease burden that diabetes
represents to our health system may require a departure from traditional
treatment models. Psychological and motivational barriers together with low
diabetes knowledge and unhelpful health practitioners were strong areas of
concern for both primary and secondary care health practitioners. Timely and
appropriate education for those with diabetes must become a priority of
treatment as this research would strongly indicate that current patient
educational initiatives are inadequate and that insufficient workforce capacity
is a major contributing cause.
This research would also suggest that tailored solutions are
required to address the differences found between these two groups of health
practitioners. For those with diabetes, primary health care workers perceive
financial barriers as a major factor in accessing adequate primary health care,
alongside the barriers of inadequate knowledge of available services and low
public awareness of the disease.
Respondents working in secondary care indicate that further
barriers include inadequate workforce capacity in the face of rapidly escalating
incidence of diabetes, inadequate community-based services and inappropriate
cultural messages.
Competing interests: None known.
Author information: Steven Lillis, Senior
Lecturer in General Practice, Waikato Clinical School, Bryant Education Centre,
Hamilton, New Zealand; Judith Swan, Associate Research Fellow, Dean's Office,
Faculty of Medicine, University of Otago, Dunedin, New Zealand; Jarrod Haar,
Senior Lecturer, School of Management, University of Waikato, Hamilton, New
Zealand; David Simmons, Institute of Metabolic Science, Cambridge University
Hospitals NHS Foundation Trust, Cambridge, England
Correspondence: Steven Lillis, Senior
Lecturer in General Practice, Waikato Clinical School, Bryant Education Centre,
Private Bag 3200, Hamilton, New Zealand. Email: lilliss@waikatodhb.govt.nz
Acknowledgements: We acknowledge the
Waikato Local Diabetes Team and the Waikato Medical Research Foundation for
their financial support.
References:
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