| BackgroundType 2 Diabetes mellitus(T2DM)has rapidly become one of the most common non-communicable diseases globally,and one of the most challenging public health issues.In China,T2DM had high prevalence,low awareness rate,low treatment rate,and low control rate,bringing heavy disease and economic burden to both individuals,families and the society.The approach to care for diabetes,different from the acute disease-oriented approach,requires the provision of long-term,multi-faceted health services.Thus,the health care delivery should move towards strategies to deal with diabetes,including the provision of the health education,behavioral interventions,drug treatment and rehabilitation care.Evidences from the global practices showed that community-based diabetes management(CDM)is a key strategy for the control of T2DM.In China,the practice of CDM began in the 1990s,and were implemented nationwide in 2009 when the new round of health system reform was initiated,as one of the key contents of the national essential public health services(EPHS).Although CDM was recognized as the preferred approach to the control of diabetes,patients' needs for health care were not fully met under the framework of EPHS;Meanwhile,the blood glucose control was not improved as expected.Thus,it is an urgent task to determine the problems and obstacles existed in the health delivery system,and to improve the effect of CDM.In the literature,majority of the researches on the effect and problems of CDM were from the perspective of the patients,focusing on blood glucose control,self-management behavior,service utilization and satisfaction,etc.;little study systematically evaluate the effect of CDM from the perspective of the health system.In terms of research methods,previous researches mostly were descriptive,and the policy evaluation methods were not used to explore the inner relationship between influences of CDM.Furthermore,previous studies few analyzed the relationship between the health system related factors with the effect of CDM,although some studies had explored the individual factors that influencing the effect.Based on previous researches,this study hopes to provide answers to the following questions through further theoretical and empirical research.First,how effective is the CDM under the framework of EPHS in China?Second,what were the factors that influence the effect of CDM,including health system-related factors and individual factors?Last,how to further improve the effect of CDM in China?ObjectivesThe overall objectives of this study were to evaluate the effect of CDM diabetes under the framework of EPHS in China,to explore the factors influencing the effect of CDM,thus to provide key strategies for optimizing CDM from both the patients' and providers'sides.The specific aims included:(1)to construct the comprehensive framework and empirical models for the analysis of factors influencing the effect of CDM in China,guided by the WHO Health System Framework and Social Cognitive Theory;(2)to analyze the status of glycemic control among T2DM patients,and explore its relationship with the utilization of CDM services and self-management behaviors;(3)to analyze the self-management behaviors from patients' side,and explore the cognitive and psychological factors that influence the self-management behavior among T2DM patients;(4)to analyze the delivery of CMD services in primary care,to identify the gaps between the delivery and utilization of CMD services,and to explore the health system related factors contributing to the gaps;(5)to provide the strategies or suggestions for improving CMD from both the patients' and providers' sides.MethodsThis is a cross-sectional study in Shandong province.A comprehensive framework for the analysis of the factors influencing the effect of the CMD was designed based on the WHO Health System Framework and Social Cognitive Theory,and three empirical models drawn from the analytical framework were used to reveal the mechanisms of how the health system-related and the patients-related factors influencing the effect of the CMD.More specifically,the first empirical model was used to analyze the factors influencing the T2DM patients' blood glucose control,compromising of main effect models and interaction effect models;The second empirical model was used to analyze the factors influencing the T2DM patients' self-management behaviors from the patients' side.The third empirical model was used to analyze the factors contributing to the gaps between the delivery and the utilization of the CMD services.In these empirical models,key indicators were glycemic control,provision and utilization of the CMD services,self-management behavior,patient cognitive and psychological factors,and health system-related factors.The data of this study is mainly from the project of the baseline survey of the community-based diabetic integration of prevention,treatment and management intervention trial in Shandong province,China,which was implemented from April 2016 to April 2018.In total,eight counties(districts)in Shandong Province were selected as the study sites based on their geographic location(east,central and west)and economic development status within the province.Data collection consisted of quantitative and qualitative parts.The quantitative data collection included fasting blood glucose testing and questionnaires survey for the patients,questionnaires survey for the primary health institutions(PHIs)and the questionnaires survey for the work staff in PHIs;The qualitative data collection included policy document collection,in-depth interviews with the key stakeholders and focus group discussions among the work staff in PHIs.In total,2,166 patients' data(response rate:86.0%),86 institutional questionnaires and 444 medical staff questionnaires were collected in this study.Meanwhile,134 key persons were interviewed and 8 focus groups discussion were organized.In this study,multivariate logistic regression was used to analyze the main effects of CMD and patient self-management behaviors on glycemic control among T2DM patients;The classification and regression tree models were used to identify possible interactions among the factors influencing patients' glycemic control;Interaction analysis was used to analyze the size of the interactions identified by the classification and regression tree models.Latent class analysis was used to explore the observed classes of self-management behaviors.Mediation analysis was used to analyze the relationships between diabetic knowledge,self-efficacy,and clusters of self-management behaviors.Multi-level models were used to identify the health system-related factors contributing to the gaps between the provision and utilization of CMD services.Thematic framework analysis was used to analyze the interview data.Results1.The glycemic control status of the participants:Among the 2166 participants,the average value of the fasting plasma glucose(FPG)was 8.0 mmol/L,and 42.8%achieved the target values of FPG<7.0mmol/L.T2DM patients with mild disease have a higher blood glucose control rate than these with severe disease.(48.7%v.s 36.9%,p<0.05;Patients with mild disease were these who were diagnosed with diabetes for less than 10 years and reported not having any diabetic complications;Patients with severe disease were these who were diagnosed with diabetes for no less than 10 years or these who reported having one or more diabetic complications.)2.The delivery&utilization of CMD services and patients' self-management behaviors:In terms of service provision,CMD services mainly include drug treatment services,follow-up management services,and health education services under the framework of the EPHS,and were provided by township-level or village-level PHIs,with the latter accounting for the majority.Both the township-level and village-level had reported providing all the diabetes management services required by EPHS for the DM patients.In terms of the services utilization,36.7%T2DM patients purchased their hypoglycemic agents from the PHIs,49.5%purchased their hypoglycemic agents outside the PHIs,and 13.9%were not on drug treatment;49.6%T2DM patients utilized the required follow-up management services delivered by PHIs;57.9%T2DM patients had once used the health education services delivered by PHIs.In terms of patients'self-management behaviors,the proportions of T2DM patients performing diet control,physical exercise,regular medication and self-monitoring of blood glucose were 74.5%,54.6%,50.4%and 25.8%,respectively.A two-class solution for self-management behaviors was tested to be the fittest based on latent class analysis;We labelled active and inactive self-management groups.The estimated proportions of T2DM in the active and inactive groups were 65.7%and 34.3%,respectively.3.The factors influencing glycemic control:Among T2DM patients with mild disease,these who were not on drug treatment(OR=3.07,95%Cl:2.05?4.60)and had utilized the health education services delivered by PHIs(OR=1.38,95%CI:1.05?1.80)were more likely to control their blood glucose;Meanwhile,T2DM patients who purchased their hypoglycemic agents outside the PHIs and didn't do physical exercise(OR=0.87,95%CI:0.77?0.97),who didn't fully utilize the follow-up management services delivered by PHIs and performed self-monitoring of blood glucose at least once per month(OR=0.48,95%CI:0.30?0.78),who didn't utilize the health education services delivered by PHIs and performed self-monitoring of blood glucose at least once per month(OR=0.62,95%CI:0.41?0.94)were less likely to control their blood glucose based on interactive analysis.Among T2DM patients with server disease,these patients who were aged ?65 years(OR=1.61,95%CI:1.22?2.14),were married(OR=1.67,95%CI:1.13?2.47),had higher household income(p<0.05),and were not on drug treatment(OR=6.22,95%CI:3.36?11.5)were more likely to control their blood glucose.T2DM patients who were on regular medication(OR=0.71,95%CI:0.54?0.93)and performed self-monitoring of blood glucose at least once per month(OR=0.62,95%CI:0.45?0.84)were less likely to control their blood glucose.Meanwhile,The patients who did not utilize follow-up management services provided by PHIs and took medication irregularly(OR=0.77;95%CI:0.63?0.89),who did not control diet and took medication irregularly(OR=0.64;95%CI:0.47?0.87),who did not control diet and did not do physical exercise(OR=0.58,95%CI:0.35?0.95),who did not do physical exercise and took medication irregularly(OR=0.60,95%CI:0.40?0.89)were less likely to control their blood glucose based on interactive analysis.4.The factors influencing self-management behaviors:Among the participants,the average score of diabetes knowledge was 10.3 points(out of 16 points),with a correct response rate of 64.7%.The average self-efficacy score of patients was 31.9 points(out of 40 points).Spearman correlation analysis indicated that there were positive correlations between diabetes knowledge,self-efficacy and self-management behaviors(p<0.05).Medication analysis indicated that self-efficacy was an important mediating variable between patients' diabetes knowledge and self-management behavior,and the mediating.effect accounted for 25.3%of the total effect.5.The health system related factors contributing to the gaps between the delivery and utilization of CDM services:The drug treatment services and health education services delivered by the village-level PHIs had higher patients' utilization rate than that delivered by township-level PHIs(p<0.001).However,there was no statistically significant difference in the utilization rate of follow-up management services between the village-level and township-level PHIs(p>0.05).Generally,Township-level PHIs that were in rural areas,equipped with more types of antidiabetic drug,had larger number of healthcare providers per 1,000 people,and had better the knowledge level of medical staff,were associated with higher patients' utilization rate of CDM services.Village-level PHIs equipped with more types of antidiabetic drug were associated with higher patients' utilization rate of drug treatment services.Village-level PHIs that had larger number of healthcare providers per 1,000 people,had interconnected health information systems,and had stricter performance evaluation of EPHS,were associated with higher patients' utilization rate of follow-up management services.Village-level PHIs equipped with more types of antidiabetic drug,had better the knowledge level of medical staff,and had interconnected health information systems were associated with higher patients' utilization rate of health education services.Conclusions and policy implicationsThe main conclusions of this study are as followed:(1)the glycemic control rate was low in T2DM patients in Shandong province.(2)To improve the control of blood glucose,more intervention measures should be taken in communities,focusing on the improvement of the utilization of CDM in patient with mild disease,and the improvement of self-management behaviors in patients with server disease.(3)The diabetic knowledge and self-efficacy were poor among the T2DM patients,which adversely affected the patients' self-management behaviors and glycemic controls.(4)Although CDM services are available to T2DM patients under the framework of EPHS,there is a huge gap between the services provided by PHIs and those patients actually utilized.(5)The problems in health system,including incomplete equipment of antidiabetic drug,disconnection between health information systems for diabetes care,insufficient human resource,poor competency of health work staff,and irrational performance evaluation on EPHS,decreased patients' utilization of the CDM services and deteriorate the effect of CDM on patients' glycemic control.This study proposes the following policy recommendations:(1)establish the grade-based management of T2DM patients based on the severity of disease;(2)conduct empowerment-based health education program for the T2DM patients;(3)strengthen the capacity of the PHIs to provide the CDM services. |
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