Abstract
Diabetes Mellitus (DM) is one of the diseases of public health concerns of the 21st century with rising burden in developing countries. The evaluation of care for diabetes from patients’ perspective an important indicator of measuring quality of health services and improving treatment approaches but data of the nature are scarce in Nigeria. The study therefore investigated Patients’ Evaluation of the Quality of Diabetes care (PEQD) in Ibadan. This descriptive cross-sectional study recruited 384 diabetic patients from three hospitals where specialised services are offered in Ibadan. A semi-structured pre-tested questionnaire was used to collect data. A 42-point PEQD questionnaire scale was used to collect data and a score of >21 was rated as good Perceived Quality of Care (PQC). Data were analysed using descriptive statistics, chi-square test and logistic regression set at 5% level of statistical significance. Mean age of respondents was 62.5 + 10.8 years and mean diabetes duration was 8.4 + 7.6. Majority (58.3%) of the respondents didn’t know the type of diabetes they had. Patients aged less than 60 years were less likely to PQC received as good (OR: 0.21; CI: 0.05 – 0.91) compared to those who were above 60 years. More than half (55.0%) of the respondents perceive quality of care as good. Patients’ assessment of the quality of diabetes care received was perceived good. There is need to sustain current satisfactory services in diabetic care and institutionalize periodic survey patients’ satisfaction to provide feedback for future quality improvement.
Keywords: Diabetes mellitus, non-communicable diseases, Quality of care, Ibadan
INTRODUCTION
Diabetes Mellitus (DM) is one of the emerging diseases of public health concerns of the 21st century. Diabetes remains a major global public health challenge that has been identified as one of the leading risk factors for other chronic non-communicable diseases' morbidity and mortality as well as all-cause mortality (WHO 2002; Chobanian et al. 2003). Estimates from the (International Diabetes Foundation (IDF) 2013), shows that 382 million people were living with diabetes globally with Africa bearing 4.9% of this burden. According to IDF (2015) more than 321,100 deaths in the Africa Region could be attributed to diabetes; 79.0% of those deaths occurred in people under the age of 60, the highest proportion of any region of the world. In Nigeria, the prevalence of DM has varied from 0.65% in rural to 11.0% in urban areas (Chinenye et al. 2012) and more than doubled over the past two decades (Balogun & Gureje 2013) and estimates. In sub-Saharan Africa, where resources are often lacking and governments may not prioritise screening for diabetes, the proportion of people with diabetes who are undiagnosed is as high as 90% in some countries (IDF 2013). According to global estimates for 2010 and 2030 the prevalence of diabetes in Nigeria in 2010 was 4.7% and is projected to be 5.5% in 2030 when compared with world population (Shaw et al. 2010).
Quality of diabetes care is critical to achieving successful diabetes treatment outcomes. From literatures, studies that examine patients’ satisfaction on the quality of diabetic care received are scarce in Nigeria, with more and more studies on prevalence and poor knowledge of the disease among patients and people at risk (Chinenye & Young 2011; Osuji et al. 2012; Mezie-Okoye 2013; Jasper et al. 2014). The importance of incorporating the perspective of the patient when evaluating and designing health care programs which is centred on the factors associated with patients’ perceived quality of diabetes care, is now widely recognized, most especially in the developed countries (Hekkink et al. 2003; Oluwole et al. 2013). Patient-based assessments of medical care are being used to measure the quality of health care (Ajayi et al. 2005; Peltzer 2009).
Patients perceive and assess the quality of care being received in different dimensions like medical personnels attitude, interpersonal relationship of health workers waiting time, communication between doctors and patients, next appointment date, respect for patients opinion during consultations, respect for patients preference and so on (Faxelid et al. 1997; Lesley 1999; Akande 2002; Jenkinson et al. 2002; Margolis et al. 2003; Oyo-Ita et al. 2007; Bleich et al. 2009; Doubova et al. 2009; Tung & Chang 2009; Sambo et al. 2010). Several studies have identified prolonged waiting times as the main component of patient dissatisfaction which affects the perceived quality of care (Ademola-Popoola et al. 2005; Eze & Okaro 2006; Chisholm & Askham 2006; Ariba et al. 2007; Tung & Chang 2009). In Nigeria, several studies stated that respondents complained of long waiting time between one to four hours to see their doctor and consultants (Ademola-Popoola et al. 2005; Eze & Okaro 2006; Sambo et al. 2010).
Evidence from Pera (2011), however, suggests that in the assessment of health care services, patients often feel left out regarding their health and therefore not able to provide feedback as a result of not being listened to, respected, trusted and included in decision making. Assessment of quality of diabetes care can help health care providers reappraise current practices and ensure patients always get the best form of care. Kerr (2008) noted that it is important to capture important elements of how patients with chronic disease perceive the quality of care received when looking at how to implement measures to assess patients’ perspectives of quality of care.
Unfortunately, as observed by Ridgeway et al. (2013), till date only few studies have collected routine, real-time information about diabetes care and management, and the available information are mostly available for developed countries. In Nigeria, the “landmark Diabcare study” conducted in 2008 that determined the status of diabetes care in Nigeria had a major flaw in the outcome assessment. The study failed to evaluate patients’ perception of medical care received and treatment satisfaction; rather only clinical and laboratory profiles were used to evaluate the quality of care (Chinenye et al. 2012). Hence, the inferences from that study to the effect that sub-optimal glycaemic control, prevalent hypertension, not meeting blood pressure targets, and prevalent chronic complications of DM among most Nigerian diabetic patients may be indicative of this methodological flaw. This is because studies have shown that satisfaction with medical care is associated with glycaemic control and risk of DM complications (Pouwer & Snoek, 2002).
Patients’ experiences with the health system will determine their attitude toward health institutions; determine their return visit, compliance with treatment and achievement of better treatment success (Olumide 1997). Therefore monitoring of patients’ experiences of health care can provide organizations with a yard stick against which to measure the quality of their services (Coulter & Ellins 2006). It becomes imperative therefore to conduct studies which document DM patients’ perception of the quality of medical care in various health facilities in sub-Saharan African countries like Nigeria which suffers a disproportionate burden of the disease, possesses fragile health care systems and where such studies are largely lacking. This study was designed to assess diabetic patients’ evaluation of the quality of diabetes care and its factors in hospitals in Ibadan metropolis. It is hoped that findings from this study would improve diabetes health care services and close the gap between health care providers’ and patients’ towards the quality of diabetes care and management services delivered in health facilities in Nigeria.
MATERIALS AND METHODS
Ethical consideration
This study was approved by relevant ethics review committee. A pre-survey visit was made to the study sites during which discussions were held with the administrators and heads of diabetes clinic in all three hospitals. Patients were enlightened about the survey and eligible respondents gave written informed consent and signed the informed consent form. Confidentiality was assured and participation in the study was totally voluntary without any compulsion. Withdrawal from the study had no consequences.
Study design, setting
The study was a cross sectional research design and was conducted among diabetic adults accessing care in endocrinology units of three (3) health care facilities [University College Hospital (UCH), Michael Bella Hospital (MBH), and Our Lady of Apostle (OLA)] within Ibadan Metropolis. UCH is a tertiary hospital, MBH is a private hospital and OLA is a missionary hospital in Ibadan, Oyo State, Nigeria. These three hospitals have highly specialized clinics in Ibadan for diabetic patients.
Sampling size, technique, and inclusion criteria
The study recruited Three hundred and eighty-four (384) consenting adults aged ≥18 years with confirmed diagnosis of type 1 or 2 diabetes by a health care practitioner at least 12 months before commencement of the study were enrolled. Also pregnant women were excluded from the study.
Data Collection
A pre-tested questionnaire was used in obtaining information from respondents. The questionnaire was pre-tested at a private specialist hospital in Ibadan, to establish the validity of the instruments. The data were analysed using SPSS version 20 and reliability of the instrument was assessed using Cronbach’s alpha for internal consistency which gave a value of 0.7 indicating a good degree of internal consistency. Necessary changes were however made thereafter to increase the validity and reliability of the questionnaire before final administration to the study respondents. Data on 4 key areas were obtained including socio-demographic characteristics, history of illness, practices relating to diabetes care/medication, and Patients Evaluation of Quality of Diabetes (PEQD). It was translated into Yoruba language which is the dominant local means of communication among respondents for individuals who are more comfortable with the local language. Respondents were assisted in filling the questionnaires by trained research assistants.
Assessment of quality of diabetes
The PEQD questions were adapted from Pouwer & Snoek (2002). The PEQD has 14 different questions covering different aspect of diabetes care including waiting times, clarity of information, emotional support, usefulness of information received, and opportunity to share decisions with the medical personnel. It evaluated quality of diabetes care on a scale a 3-point scale (1 [poor], 2 [fair], and 3 [good]) and domains were computed as a score.
Data Analysis
Data summary was achieved using frequencies, proportions, means and standard deviations; while association were evaluated using Chi-square test. Logistic regression was used to identify factors associated with patients’ evaluation of diabetes care and diabetes medication satisfaction. Bivariate and multivariate tests analyses were interpreted at 5% level of significance and 95% Confidence Interval (CI).
Duration of diabetes care was summarized and a cut-off of value of 8 was used to dichotomize it. Socioeconomic status (SES) was computed in binary form, extraction of variables was done using principal component analysis (PCA) and scree plot. The system extracted 6 variables, which were computed to generate the wealth score. The scores were categorised as poor, average, and wealthy.
Practices relating to diabetes care and medication score was a combination of eight items. A score of one point was given to each correct response and zero for wrong responses. The total obtainable score was 8 based on these eight items. Fifty percent (50%) of this total score which is five (5) was chosen as cut-off for good practise relating to diabetes care and medication. The PEQD has 14 different questions with a 3-point scale and total obtainable point was 42. A cut-off value of 21 was used to dichotomize poor and good perceived quality of care.
RESULTS
Socio-demographic characteristics of respondents
There were 35.9% males and 64.1% females, while the mean age was 62.5 + 10.8 years. Majority (80.2%) of the respondents were married, and less than half of the respondents (40.6%) had post-secondary school education, those with no formal education account for 16.4%. Two hundred and forty two (63.0%) of the respondents were Christians while 140 (36.5%) were Muslims. Majority (89.3%) of respondents were also of the Yoruba ethnic group while others constituted 10.2%. The wealth index showed that 51.8% of the respondents were poor, while 22.3% and 25.5% of the respondents were of average wealth status and wealthy respectively.
Profile of diabetic patients
Table 1 shows the profile of diabetics patients studied. More than half (58.3%) self-reported the type of diabetes they had. The mean duration on care was 8.4 + 7.6 years. Majority of respondents (62.0%) reported being on DM care for less than 8years and more than half of the respondents (56.3%) reported that apart from DM they suffered from other comorbidities like eye problems, cardiovascular problem, kidney problem, nerve damage and complaints of diabetic foot. A large proportion of the respondents reported that no immediate family member or extended family member had ever been diagnosed with diabetes (61.7%). Majority (94.3%) of the patients reported carrying out self-monitoring of their sugar levels, while 97.4% reported taking their drugs as prescribed; although only 61.7% reported normal blood sugar levels during the last check.
Table 1.
Profile of Diabetic Patients. (N=384)
| Frequency | % | |
|---|---|---|
| Type of Diabetes (Self-reported) | ||
| Type 1 | 20 | 5.2 |
| Type 2 | 140 | 36.5 |
| Don’t Know | 224 | 58.3 |
|
| ||
| Duration on DM care | ||
| ≤ 8 years | 238 | 62.0 |
| > 8 years | 144 | 37.5 |
|
| ||
| Comorbidities | ||
| Yes | 216 | 56.3 |
| No | 168 | 43.8 |
|
| ||
| Self-reported complication | ||
| Eye problem | 179 | 32.1 |
| Kidney disease | 118 | 21.2 |
| Cardiovascular problem | 130 | 23.3 |
| Diabetic foot | 50 | 9.0 |
| Nerve damage | 80 | 14.4 |
|
| ||
| Family history – 10 relatives | ||
| Yes | 147 | 38.3 |
| No | 237 | 61.7 |
|
| ||
| Family history – 20 relatives | ||
| Yes | 52 | 13.5 |
| No | 329 | 85.7 |
| Don’t Know | 3 | 0.8 |
|
| ||
| Do you monitor your sugar level | ||
| Yes | 362 | 94.3 |
| No | 22 | 5.7 |
|
| ||
| Last blood sugar check | ||
| Normal (45 – 100mg.dL) | 237 | 61.7 |
| High (>120mg.dL) | 106 | 27.6 |
| Don’t Know | 19 | 4.9 |
|
| ||
| Self-reported adherence with prescribed drugs | ||
| Yes | 374 | 97.4 |
| No | 10 | 2.6 |
Mean duration on care: 8.5 ± 7.6 years
Patients’ evaluation of the quality of Diabetes care
Table 2 shows Patients’ evaluation of the quality of diabetes care. Overall evaluation showed that 51.6% of the respondents perceived quality of care as good while 48.4% respondents perceived it as poor. Although majority (73.4%) of respondents reported that waiting time spent before consulting with a doctor was poor,78.9% said time spent during consultation with the doctor was good, while 84.4% and 84.1% of respondents said clarity and usefulness of information received during such consultation was good. Over 80% of respondents also said the amount of information received from the doctor, opportunity to ask questions during consultation was perceived as good. Although majority of the respondents (75.3%) said the extent to which the doctor was informed about their past treatment was good, more than half of the respondents (63.3%) said the opportunity to share and be part of decisions with the doctor about their diabetes treatment was poor.
Table 2.
Patients Evaluation of Quality of Diabetes Care (N=384)
| Poor (%) | Good (%) |
|
|---|---|---|
| Waiting time before consulting with a doctor | 282 (73.4) | 102 (26.6) |
|
| ||
| Time spent with the doctor during consultation | 81 (21.1) | 303 (78.9) |
|
| ||
| Waiting time before next clinical appointment | 175 (45.6) | 209 (54.4) |
|
| ||
| Clarity of information received from the doctor | 60 (15.6) | 324 (84.4) |
|
| ||
| Amount of information received from the doctor | 74 (19.3) | 310 (80.7) |
|
| ||
| Usefulness of information received from the doctor | 61 (15.9) | 323 (84.1) |
|
| ||
| The opportunity to ask questions during consultation | 74 (19.3) | 310 (80.7) |
|
| ||
| Emotional support given by the doctor | 130 (33.9) | 254 (66.1) |
|
| ||
| Doctor’s ability to maintain/achieve favourable effects on your diabetes | 111 (28.9) | 273 (71.1) |
|
| ||
| The extent to which the doctor is informed about the past treatment of my diabetes | 95 (24.7) | 289 (75.3) |
|
| ||
| The extent to which the diabetes care provided by the doctor is integrated with the care of other clinics that I have visited | 147 (43.0) | 195 (57.0) |
|
| ||
| The opportunity to share and be part of decisions with the doctor about my diabetes treatment | 251 (65.4) | 133 (34.6) |
|
| ||
| The ease of making new appointments with the doctor | 153 (39.8) | 231 (60.2) |
|
| ||
| The overall quality of my diabetes care by the doctor | 108 (28.1) | 276 (71.9) |
|
| ||
| Overall perceived quality of DM Care | ||
| Poor | 154 (45.0) | |
| Good | 188 (55.0) | |
Relationship between perceived quality of care and socio demographic characteristics
Results in table 3 shows that age, marital status, level of education, health facility, religion and wealth index were significantly associated with perceived quality of diabetes care. The percentage of patients who perceived the quality of care received as good was significantly higher among those who were married and completed post-secondary education when compared with others. Proportion of patients who perceived the quality of care received as good were significantly higher among those accessing care from a private hospital (96.7%) compared to those accessing care from either government hospital (68.2%) or a missionary hospital (21.3%). Consequently, more wealthy patients (73.9%) perceived the quality of care received as good compared to the average (68.0%) or poorer patients (59.0%).
Table 3.
Relationship between perceived quality of care and history of diabetes illness
| Poor N (%) |
Good N (%) |
P value | |
|---|---|---|---|
| Type of Diabetes (Self-reported) | |||
| Type 1 | 1 (7.1) | 13 (92.9) | |
| Type 2 | 29 (22.5) | 100 (77.5) | < 0.01 |
| Don’t Know | 90 (45.2) | 109 (54.8) | |
|
| |||
| Duration on DM care | |||
| ≤ 8 yrs | 83 (40.5) | 122 (59.5) | 0.01 |
| > 8yrs | 37 (27.4) | 98 (72.6) | |
|
| |||
| Comorbidities? | |||
| Yes | 103 (47.7) | 113 (52.3) | 0.87 |
| No | 83 (49.4) | 85 (50.6) | |
|
| |||
| Family history – 10 relatives | |||
| Yes | 67 (34.7) | 126 (65.3) | 0.51 |
| No | 53 (35.6) | 96 (64.4) | |
|
| |||
| Family history – 20 relatives | |||
| Yes | 16 (30.8) | 36 (69.2) | 0.775 |
| No | 103 (35.9) | 184 (64.1) | |
|
| |||
| Monitoring of blood sugar level(last one month) | |||
| Yes | 101 (31.6) | 219 (68.4) | < 0.01 |
| No | 19 (86.4) | 3 (13.6) | |
|
| |||
| Frequency of blood sugar monitoring | |||
| Daily | 19 (32.8) | 39 (67.2) | 0.02 |
| Weekly | 28 (26.2) | 79 (73.8) | |
| Monthly | 38 (41.8) | 53 (58.2) | |
|
| |||
| Last blood sugar check | |||
| Normal (45 – 100mg.dL) | 68 (31.9) | 145 (68.1) | 0.94 |
| High (>120mg.dL) | 28 (31.5) | 61 (68.5) | |
| DK | 5 (27.8) | 13 (72.2) | |
|
| |||
| Adherence with prescribed drugs | |||
| Yes | 114 (34.3) | 218 (65.7) | 0.09 |
| No | 6 (60.0) | 4 (40.0) | |
Other variables such as gender of respondents and ethnicity were not statistically associated with perceived quality of care.
Relationship between perceived quality of care and diabetes’ related characteristics
In table 4, type of diabetes, duration of diabetes care received, self-monitoring of sugar levels and frequency of sugar level monitoring were significantly associated with perceived quality of care. Patients who perceived the quality of care received as good were significantly higher among those with T1D (92.9%) than those with either T2D (77.5%) or those unaware of their DM being treated for (54.8%); also, patients that had been on diabetes care for more than 8 years (72.6%) perceived their quality of care as better than those who had been on diabetes care for less than 8years (59.5%). Patients who reported perceived quality of care as good were significantly higher among those who monitored their sugar levels weekly (73.8%) compared to those who monitored theirs daily (67.2%) or monthly (58.2%).
Table 4.
Relationship between perceived quality of care and history of diabetes illness (N=384)
| Poor N (%) |
Good N (%) |
p value | |
|---|---|---|---|
| Type of Diabetes (Self-reported) | |||
| Type 1 | 1 (7.1) | 13 (92.9) | < 0.01 |
| Type 2 | 29 (22.5) | 100 (77.5) | |
| Don’t Know | 90 (45.2) | 109 (54.8) | |
|
| |||
| Duration on DM care | |||
| ≤ 8 yrs | 83 (40.5) | 122 (59.5) | < 0.01 |
| > 8yrs | 37 (27.4) | 98 (72.6) | |
|
| |||
| Comorbidities? | |||
| Yes | 103 (47.7) | 113 (52.3) | 0.87 |
| No | 83 (49.4) | 85 (50.6) | |
|
| |||
| Family history – 10 relatives | |||
| Yes | 67 (34.7) | 126 (65.3) | 0.51 |
| No | 53 (35.6) | 96 (64.4) | |
|
| |||
| Family history – 20 relatives | |||
| Yes | 16 (30.8) | 36 (69.2) | 0.775 |
| No | 103 (35.9) | 184 (64.1) | |
|
| |||
| Monitoring of blood sugar level(last one month) | |||
| Yes | 101 (31.6) | 219 (68.4) | < 0.01 |
| No | 19 (86.4) | 3 (13.6) | |
|
| |||
| Frequency of blood sugar monitoring | |||
| Daily | 19 (32.8) | 39 (67.2) | 0.02 |
| Weekly | 28 (26.2) | 79 (73.8) | |
| Monthly | 38 (41.8) | 53 (58.2) | |
|
| |||
| Last blood sugar check | |||
| Normal (45 – 100mg.dL) | 68 (31.9) | 145 (68.1) | 0.94 |
| High (>120mg.dL) | 28 (31.5) | 61 (68.5) | |
| DK | 5 (27.8) | 13 (72.2) | |
|
| |||
| Adherence with prescribed drugs | |||
| Yes | 114 (34.3) | 218 (65.7) | 0.09 |
| No | 6 (60.0) | 4 (40.0) | |
Other variables including presence of other illness, familial history of diabetes, level of blood sugar and taking prescribed drugs were not significantly associated with DM treatment satisfaction.
Relationship between the perceived quality of diabetes care and other factors
After adjusting for other factors, accessing diabetes care from a private health facility and age (50–59 years) were statistically associated with perception of the quality of DM care being received (Table 5).
Table 5.
Binary logistic regression between the perceived quality of diabetes care and other factors (N=384)
| Odds Ratio (OR) |
95% C.I. for OR |
p value | |
|---|---|---|---|
| Religion | |||
| Christianity | 1.69 | 0.697 – 4.11 | 0.33 |
| Islam (Ref) | |||
|
| |||
| Health facility | |||
| Private | 19.57 | 3.34 – 114.46 | 0.01 |
| Missionary | 2.06 | 0.42 – 9.98 | 0.44 |
| Government (Ref) | - | - | - |
|
| |||
| Age | |||
| 50 – 59 years | 0.21 | 0.05 – 0.91 | 0.08 |
|
| |||
| > 60 years | 0.59 | 0.14 – 2.46 | 0.54 |
| ≤ 49 years (Ref) | - | - | - |
|
| |||
| Wealth Index | |||
| Average | 1.43 | 0.53 – 3.86 | 0.56 |
| Wealthy | 0.65 | 0.23 – 1.81 | 0.49 |
| Poor (Ref) | - | - | - |
|
| |||
| Type of diabetes (self-reported) | |||
|
| |||
| Type 2 | 4.02 | 0.6 – 27.01 | 0.23 |
| Type 1 (Ref) | - | - | - |
|
| |||
| Duration of diabetes care | |||
| ≤ 8 yrs | 0.8 | 0.3 – 2.15 | 0.71 |
| > 8yrs (Ref) | - | - | - |
Patients accessing care from private hospital were about 20 times more likely to perceive the quality of care received as good (OR: 19.57, 95% CI: 3.34 – 114.46) compared to those accessing care from government hospital. Patients aged between 50–59 years were also about five times less likely to perceive the quality of care received as good (OR: 0.21; 95% CI: 0.05 – 0.91) compared to those who were above 60 years. Type of diabetes was not statistically associated with perception of the quality of DM care although patients with type 2 diabetics were about 4 times more likely to perceive the quality of care received as good (OR: 4.02; 95% CI: 0.6 – 27.01) compared to type 1 diabetics
DISCUSSION
This study showed that diabetes patients’ perceived the quality of care in the study area good. The indication of quality of diabetes care perceived to be poor were waiting time and opportunity to be part of decisions with the doctor about treatment. Although the private hospital had a better waiting time and government hospital had a better proportion of respondents that were part of the decision-making process regarding the diabetes treatment. Several authors have shown that patients are generally dissatisfied with the long waiting time before seeing the doctor or getting drug prescription from the pharmacist for any care which could be as long as four (4) hours in some teaching hospitals in Nigeria (Ademola-Popoola et al. 2005; Eze & Okaro 2006) and other settings (Sambo et al. 2010; Umeano-Enemuoh et al. 2014).
Long waiting time may arise from poor time and patient management, it can also be due to insufficient health personnel including doctors, nurses, and pharmacists amongst others leading to further worsening of patients’ health conditions and patients satisfaction with care. Chisholm & Askham (2006) opined that the greatest need for improvement in health care service delivery is in the area of patients’ waiting time.
Other indicators (like time spent during consultation, waiting time before next appointment, clarity of information received, amount and usefulness of information received from the doctor, opportunity to ask the doctor questions during consultation, emotional support received from the doctor, the extent to which the doctor is informed about the patients past diabetes treatment, the doctors ability to maintain and achieve favourable result and the ease of making new appointments) were generally perceived as good.
Socio-demographic factors were significantly associated with having good perception of quality of care received. These factors include age of respondent, type of health facility, religious affiliation and wealth status. However, only age of respondent and type of health facility were significant at multivariate analysis. Findings from Ziaei et al. 2011 and Ibraheem et al. 2013 revealed that older diabetics (patients aged 60 years and above), had greater odds of perceiving the quality of care received as good compared to younger diabetic patients and this can be attributed that the elderly tend to believe their illness is due to old age and thus have lower expectations compared to younger age groups
There was variation in perceived the quality of care received amongst health facilities. Variation in the type of services available to patients may explain the difference in quality of care as these health care facilities present different care settings. Besides, several studies have previously shown that variation in diabetes management occurs in different settings even within the same health system (Suwattee et al. 2003; O’Connor et al. 2011). Private health facilities tend to provide better health services not obtainable in either government or missionary health facilities.
Affordability is always important in the perceptions of quality of healthcare services. The reason for the observed better perception of quality of services received from private hospitals may therefore be connected with the higher wealth index of patients accessing care from these facilities since they are better able to afford the higher fees charged. More so, Basu et al. (2012) noted that private sector healthcare systems tend to serve higher socio-economic groups, whereas the public sector tended to be less responsive to patients and lacked availability of supplies. A review comparing the performance of private and public healthcare systems in low- and middle-income countries did not support the claim that the private sector was usually more efficient, accountable, or medically effective than the public sector as nine studies reviewed found that diagnostic accuracy and adherence to medical management standards were worse among private than public sector care providers; they did observe that the public sector appeared to frequently lack timeliness and hospitality towards patients (Basu et al. 2012).
Regular self-monitoring of sugar level was significantly associated with perception of quality of care both at the bivariate and multivariate analysis. Diabetic patients who reported carrying out self-monitoring of sugar levels were about 4 times more likely to perceive the quality of care received good compared to those who didn’t monitor their sugar levels. Self-management behaviours, especially regular Self-Monitoring of Blood Glucose (SMBG) is useful for prompt detection of fluctuations in diabetics’ blood glucose levels and has been found to be associated with optimum diabetes health care outcomes. Most patients get to check their sugar levels when they make visits to the clinics due to the cost of the blood glucose monitoring device especially in a developing country like Nigeria. They may tend to perceive carrying out regular self-monitoring of their sugar levels as unimportant or an extra financial burden due to cost of the device. Although the practice of SMBG does not necessarily mean patient is compliant with prescribed treatment recommendations. It may however be an indication of active commitment of patient to his/her diabetes management.
In conclusion, the overall evaluation of quality of diabetes care received by patients’ was perceived as good. Although there was a significant difference in the perceived quality of diabetes care along the type of health facility. Good and adequate knowledge of diabetes and its risk factors are important for diabetics and needed for effective self-care management of the disease including necessary lifestyle modifications (such as dietary control, regular exercise and psychosocial coping skills).
There is need to develop care improvement strategies that will address the issues of waiting time, boost self-monitoring of patients health and develop service improvement plans that will reduce diabetes related morbidity, mortality and increase health outcomes. A structured consultation schedule and health care education programme is advocated to improve the quality of diabetes care. Periodic patient satisfaction survey on quality of care should be institutionalized to provide feedback for continuous quality improvement.
The study had several limitations. The researcher had to rely upon self-reported responses and recall bias is a possibility. Secondly, patients’ who consented were enrolled non-randomly and consecutively from the clinic population. Thus, this may have been heavily weighted with frequent attenders because more aggressive patients seeking care were more likely to keep appointments. Thirdly, it would have been interesting to gather data from other different sources, such as case notes and focus groups, which might have enhanced the richness, breadth, and depth of the data and the worth of the final interpretations. Another limitation was that social desirability bias might have crept in since the study was conducted at a clinic setting. However during the orientation, efforts were made to explain about the aim of the study, the confidentiality of the research process and its zero effect on the services they are receiving
Acknowledgments
The writing of this paper was supported by the University of Ibadan Medical Education Partnership Initiative Junior Faculty Training Programme (UI-MEPI-J) project funded by Fogarty International Center, National Institute of Health under Award Number D43TW010140. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding organizations..
References
- Ademola-Popoola DS, Akande TM, Idris A. Patients’ assessment of quality of eye care in a nigerian teaching hospital. The Nigerian postgraduate medical journal. 2005;12(3):145–8. [PubMed] [Google Scholar]
- Ajayi IO, Olumide EA, Oyediran O. Patient satisfaction with the services provided at a general outpatients’ clinic, Ibadan, Oyo State, Nigeria. African Journal of Medicine & Medical Science. 2005;34(2):133–140. [PubMed] [Google Scholar]
- Akande TM. Patients’ perception on communication between patients and doctors in a teaching hospital. Sahel Medical Journal. 2002;5(4):178–181. [Google Scholar]
- Ariba A, Thanni L, Adebayo O. Patient perception of quality emergency care in a Nigerian teaching hospital: The influence of patient -provider interactions. Nigeria Postgraduate Medical Journal. 2007;14(4):296–301. [PubMed] [Google Scholar]
- Balogun WO, Gureje O. Clinical Section / Original Paper Self-Reported Incident Type 2 Diabetes in the Ibadan Study of Ageing : Relationship with Urban Residence and Socioeconomic Status. Gerontology. 2013;59:3–7. doi: 10.1159/000340062. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Basu S, et al. Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries : A Systematic Review. PLOS Medicine. 2012;9(6):1–14. doi: 10.1371/journal.pmed.1001244. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Bleich SN, Ozaltin E, Murray CKL. How does satisfaction with the health-care system relate to patient experience? Bulletin of the World Health Organization. 2009;87(4):271–8. doi: 10.2471/BLT.07.050401. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Chinenye S, et al. Profile of Nigerians with diabetes mellitus – Diabcare Nigeria study group (2008): Results of a multicenter study. Indian Journal of Endocrinology and Metabolism. 2012;16(4):558–564. doi: 10.4103/2230-8210.98011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Chinenye S, Young E. State of Diabetes Care in Nigeria : A Review. The Nigerian Health Journal. 2011;11(4):101–106. [Google Scholar]
- Chisholm A, Askham J. What do you think of your doctor? Picker Institute Europe. 2006;(September):1–39. [Google Scholar]
- Chobanian AV, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA : the journal of the American Medical Association. 2003;289(19):2560–72. doi: 10.1001/jama.289.19.2560. [DOI] [PubMed] [Google Scholar]
- Coulter A, Ellins J. Patient-focused interventions: A review of the evidence. Picker Institute Europe for the health foundation’s QQUIP programme. 2006;(August):1–277. Available at: http://www.health.org.uk/publications/patient-focused-interventions/
- Doubova SV, et al. Satisfaction of patients suffering from type 2 diabetes and/or hypertension with care offered in family medicine clinics in Mexico. Salud pública de México. 2009;51(3):231–9. doi: 10.1590/s0036-36342009000300014. [DOI] [PubMed] [Google Scholar]
- Eze C, Okaro A. Survey of patient satisfaction with obstetric ultrasound service at University of Nigeria Teaching Hospital, Enugu, Nigeria. Nigerian Journal of Health and Biomedical Sciences. 2006;5(1):93–97. [Google Scholar]
- Faxelid E, et al. Quality of STD care in an urban Zambian setting: the providers’ perspective. International journal of nursing studies. 1997;34(5):353–7. doi: 10.1016/s0020-7489(97)00027-8. [DOI] [PubMed] [Google Scholar]
- Hekkink CF, et al. QUOTE-HIV: an instrument for assessing quality of HIV care from the patients’ perspective. Quality & safety in health care. 2003;12(3):188–93. doi: 10.1136/qhc.12.3.188. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Ibraheem WA, Ibraheem AB, Bekibele CO. Socio-demographic predictors of patients’ satisfaction. Afr J Med Health Sci. 2013;12(2):87–90. [Google Scholar]
- International Diabetes Federation. IDF Diabetes Atlas. (6) 2013 [Google Scholar]
- International Diabetes Federation. IDF Diabetes Atlas. (7) 2015 [Google Scholar]
- Jasper US, et al. Determinants of diabetes knowledge in a cohort of Nigerian diabetics. Journal of Diabetes & Metabolic Disorders. 2014;13(1):1–8. doi: 10.1186/2251-6581-13-39. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Jenkinson C, et al. Patients’ experiences and satisfaction with health care: results of a questionnaire study of specific aspects of care. [Accessed February 1, 2016];Quality & safety in health care. 2002 11(4):335–9. doi: 10.1136/qhc.11.4.335. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1757991&tool=pmcentrez&rendertype=abstract. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Kerr EA. Assessing Quality of Care for Diabetes. Agency for Healthcare Research and Quality. 2008:1–5. [Google Scholar]
- Lesley B. What really improves the quality of primary health care? A review of local and international experience. 1999 Available at: http://www.who.int/entity/management/district/WhatReallyImprovesQualityPHC.pdf.
- Margolis SA, et al. Patient satisfaction with primary health care services in the United Arab Emirates. International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua. 2003;15(3):241–9. doi: 10.1093/intqhc/mzg036. [DOI] [PubMed] [Google Scholar]
- Mezie-Okoye MM. Diabetes in older adults : experience from a rural community in south-east Nigeria. African Jounal of Diabetes Medicine. 2013;21(2):45–48. [Google Scholar]
- O’Connor PJ, et al. Diabetes performance measures: current status and future directions. Diabetes care. 2011;34(7):1651–9. doi: 10.2337/dc11-0735. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Olumide A. Quality of management in healthcare: Fundamentals of health service management for doctors and senior health workers in Africa. Kemta Publishers. 1997;94:94–100. [Google Scholar]
- Oluwole AB, et al. Primary health care consumers ’ perception of quality of care and its determinants in North-Central Nigeria. Journal of Asian Scientific Research. 2013;3(7):775–785. [Google Scholar]
- Osuji CU, et al. Prevalence of diabetes mellitus in a group of women attending “August meeting” at Naze South East Nigeria. Journal of Diabetes Mellitus. 2012;2(3):321–326. [Google Scholar]
- Oyo-Ita AE, et al. Patients’ perception of obstetric practice in Calabar, Nigeria. Nigerian journal of clinical practice. 2007;10(3):224–8. [PubMed] [Google Scholar]
- Peltzer K. Patient experiences and health system responsiveness in South Africa. BMC health services research. 2009;9(117):1–12. doi: 10.1186/1472-6963-9-117. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pera PI. Living with diabetes: quality of care and quality of life. Patient preference and adherence. 2011;5:65–72. doi: 10.2147/PPA.S16551. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pouwer F, Snoek FJ. Patients ’ Evaluation of the Quality of Diabetes Care. Qual itySafe Health Care. 2002;11:131–136. doi: 10.1136/qhc.11.2.131. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Ridgeway JL, et al. A Brief Patient-Reported Outcomes Quality of Life (PROQOL) Instrument to Improve Patient Care. PLOS Medicine. 2013;10(11):1–5. doi: 10.1371/journal.pmed.1001548. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Sambo MH, Lewis I, Idris SH. Quality of care in primary health centres of Tafa Local Government Area of Niger state, North central Nigeria; the clients’ perspective. Nigerian journal of medicine : journal of the National Association of Resident Doctors of Nigeria. 2010;19(2):194–8. doi: 10.4314/njm.v19i2.56519. [DOI] [PubMed] [Google Scholar]
- Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Research and Clinical Practice. 2010;87(1):4–14. doi: 10.1016/j.diabres.2009.10.007. [DOI] [PubMed] [Google Scholar]
- Suwattee P, Lynch CJ, Pendergrass ML. Quality of Care for Diabetic Patients in a Large Urban Public Hospital. Diabetes Care. 2003;26(3):563–568. doi: 10.2337/diacare.26.3.563. [DOI] [PubMed] [Google Scholar]
- Tung Y-C, Chang G-M. Patient satisfaction with and recommendation of a primary care provider: associations of perceived quality and patient education. [Accessed February 1, 2016];International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua. 2009 21(3):206–13. doi: 10.1093/intqhc/mzp006. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19258342. [DOI] [PubMed] [Google Scholar]
- Umeano-Enemuoh JC, et al. Patients’ Satisfaction and Quality of Care in a Tertiary Institution in Southeast Nigeria. International Research Journal of Basic and Clinical Studies. 2014;2(2):14–19. [Google Scholar]
- WHO. Reducing Risks, Promoting Healthy Life. [Accessed February 2, 2016];The world health report 2002. 2002 doi: 10.1080/1357628031000116808. Available at: http://www.who.int/whr/2002/en/ [DOI] [PubMed]
- Ziaei H, et al. Determinants of patient satisfaction with ophthalmic services. [Accessed February 1, 2016];BMC research notes. 2011 4:7. doi: 10.1186/1756-0500-4-7. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3037326&tool=pmcentrez&rendertype=abstract. [DOI] [PMC free article] [PubMed] [Google Scholar]