title: Primary care management of diabetes in a low/middle income country: a multi-method, qualitative study of barriers and facilitators to care.
abstract: BACKGROUND
  The management of patients with diabetes mellitus is complex. Some research has been done in developed countries to attempt to determine the factors that influence quality of care of patients with diabetes: Factors thus far postulated are usually categorised into patient, clinician and organisational factors. Our study sought to discover the main barriers and facilitators to care in the management of diabetes in primary care in a low/middle income country.
  
  
  METHODS
  A qualitative study, based on reflexive ethnography using participant observation, semi-structured interviews of clinicians (10) and group interviews with paramedical staff (4) and patients (12) in three purposively sampled health centres, along with informal observation and discussions at over 50 other health centres throughout Tunisia. A content analysis of the data was performed.
  
  
  RESULTS
  Over 400 potential barriers or facilitators to care of patients with diabetes in primary care in Tunisia emerged. Overall, the most common cited factor was the availability of medication at the health centre. Other frequently observed organisational factors were the existence of chronic disease clinics and clinicians workload. The most commonly mentioned health professional factor was doctor motivation. Frequently cited patient factors were financial issues, patient education and compliance and attendance issues. There were notable differences in the priority given to the various factors by the researcher, physicians, paramedical staff and the patients.
  
  
  CONCLUSIONS
  We have discovered a large number of potential barriers and facilitators to care that may potentially be influencing the care of patients with diabetes within primary care in Tunisia, a low/middle income country. An appreciation and understanding of these factors is essential in order to develop culturally appropriate interventions to improve the care of people with diabetes.
authors.affiliation: Institute of Health and Society, Newcastle University, 21 Claremont Place, Newcastle upon Tyne, UK, NE2 4AA. hugh.alberti@ncl.ac.uk
authors.forename: Hugh
authors.initials: H
authors.lastname: Alberti
authors.forename: Nessiba
authors.initials: N
authors.lastname: Boudriga
authors.forename: Mounira
authors.initials: M
authors.lastname: Nabli
mesh_terms: D001291:Attitude of Health Personnel; D003151:Community Health Centers / Q000458:organization & administration / Q000592:standards*; D003920:Diabetes Mellitus / Q000188:drug therapy / Q000208:ethnology / Q000628:therapy*; D005260:Female; D006297:Health Services Accessibility / Q000458:organization & administration*; D054625:Healthcare Disparities; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008485:Medical Audit; D009042:Motivation; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D010821:Physicians, Family / Q000523:psychology; D011320:Primary Health Care / Q000458:organization & administration / Q000592:standards*; D011635:Public Health Administration / Q000592:standards*; D036301:Qualitative Research; D019984:Quality Indicators, Health Care; D014416:Tunisia