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A cross-sectional study of the differences in diabetes knowledge, attitudes, perceptions and self-care practices as related to assessment of chronic illness care among people with diabetes consulting in a family physician-led hospital-based first line health service and local government health unit-based health centers in the Philippines

A cross-sectional study of the differences in diabetes knowledge, attitudes, perceptions and... Background: The purpose of this study was to investigate differences in diabetes knowledge, attitudes and perceptions (KAP), self-care practices as related to assessment of chronic illness care among people with diabetes consulting in a family physician-led tertiary hospital-based out-patient clinic versus local government health unit-based health centers in the Philippines. Methods: People with diabetes consulting in the said primary care services were interviewed making use of questionnaires adapted from previously tested and validated KAP questionnaires and the patients? assessment of chronic illness care (PACIC) questionnaire. Adherence to medications, diabetes diet, and exercise and the number of diabetes consultations were asked. Analysis of variance was used to determine differences in KAP, self-care practices, and PACIC and regression analysis was used to determine any associations of the abovementioned variables to the PACIC ratings. Results: A total of 549 respondents were included in the study. Differences in knowledge, attitudes, perceptions, PACIC, utilization of health services, and adherence to medications and exercise were all statistically significant. Ratings for diabetes knowledge, positive attitudes, and the perceptions of support attitudes and the abilities to perform self care, and the proportions of those properly utilizing health services and adhering to medications and exercise were higher while ratings for negative attitudes, perceived support needs, perceived support received and PACIC were lower among those consulting in the family physician-led health service. Conclusions: Combining family medicine-based approaches with culturally competent diabetes care may improve knowledge, attitudes, perceptions and self-care practices of and collaborative care with people with diabetes. Keywords: Biopsychosocial approach, Chronic conditions, Collaborative care, Culturally-competent care, Diabetes mellitus type 2, Family medicine principles, Perceived self-efficacy, Self-care development * Correspondence: gracemariekumd@yahoo.com Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium ? 2014 Ku and Kegels ; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ku and Kegels Asia Pacific Family Medicine 2014, 13:14 Page 2 of 9 http://www.apfmj.com/content/13/1/14 Introduction and support are provided by culturally competent care People with chronic conditions encounter many day- providers who engage these people in a collaborative to-day situations where they have to make decisions on manner using the biopsychosocial approach and family their own [1]; self-care plays an important role and medicine-based principles. collaboration rather than a health provider-directed This study compared the differences in on-going pri- care may be a more effective care model [2]. Collabora- mary diabetes care through assessments of chronic care tive care between people with chronic conditions and delivery between a family physician-led hospital-based their health care providers is better achieved if the health service where a biopsychosocial, collaborative ap- people having these chronic conditions are informed proach is practiced, and local government health units and activated [3]. Such may involve self-management edu- (LGHU) with community-based services where the care cation and skills development. However, the provision of providers and recipients of care have congruent socio- self-management education and support is not simple. cultural backgrounds, as related to diabetes knowledge, It does not only involve the development of self- attitudes, perceptions on family support, perceptions of management skills but barriers should also be addressed self-efficacy and self-care practices of people with dia- [4]. These barriers include personal, social and environ- betes utilizing these said services. mental barriers. Personal barriers include disease-related beliefs, emotions, knowledge and experiences [5]; socio- Background cultural barriers take account of the differences in lan- Family medicine in the Philippines guage, and in cultural and ethnic beliefs and perceptions Leopando and Olazo extensively discuss family medicine of health and illness [6] between the providers and the as a specialty in the Philippines [13]. A physician special- recipients of self-management development; and envir- izing in family medicine is seen as having the following onmental barriers refer to the immediate environment roles and responsibilities: health care provider, counselor, of family and friends and the wider environment of the administrator, teacher, social mobilizer and researcher. health care system and the community in supporting As a health care provider, the family physician assumes adoption of proper self-care behavior. Studies have dem- the roles of gatekeeper, primary care giver, hospice care onstrated that culturally competent self-management giver and family health care giver. As a counselor, the education improved diabetes care, self-awareness and family physician is expected to practice active listening understanding of diabetes [7] while patient-centered, skills [14] and the CEA (Catharsis, Education, Action) biopsychosocial approaches as practiced in the family methods [15]. As administrator, the family physician medicine paradigm address personal barriers [8] and takes on the roles of a coordinator and manager who improved diabetes knowledge, patient perceived self- integrates and coordinates health services for the pa- efficacy and glycemia [9-11]. tients and their families. As a teacher/educator, the It should be noted that self-management skills devel- family physician assumes the roles of trainer and health opment are usually given as part of the clinical care promoter providing education and skills development in delivered by care providers; and the background, methods, family medicine and public health. As a social mobilizer, settings, and context by which self-management education the family physician is a health advocate and a commu- and support is to be introduced and delivered should be nity health organizer promoting wellness and health optimized to ensure maximum absorption and adoption maintenance to individuals, families and the public, and of self-care behavior. In settings where such self-care empowers patients towards self-care. As a researcher, development activities are non-existent, establishing the family physician produces relevant and evidence-based current status of diabetes care and its effects on factors research outputs. Some family medicine practices are that may affect self-care is needed to prepare these health hospital-based while others are in health centers in the services in the delivery of self-management education and communities. In both settings, family medicine-based first support. line and ambulatory care services can be delivered. In an earlier publication, the investigators constructed Family medicine training in the Philippines is thus a framework for self-management education and support geared towards producing family physicians who can ful- wherein perceived self-efficacy of the person with chronic fill these roles and responsibilities. Central to this would condition plays a vital role in the adoption and adherence be training not only in the provision of biomedical care of proper self-care behavior; this perception of self-efficacy but also taking into consideration various psychosocial may be affected by internal and external influences [12]. factors that may positively or negatively affect the course In here, the investigators theorize that healthcare pro- of illness and how the person will participate in self- viders may positively influence people with chronic care. Training healthcare providers who are responsible conditions to perceive a higher degree of self-efficacy for primary care on the biopsychosocial approach has and to carry out self-care practices better if education long been advocated [16,17]. Ku and Kegels Asia Pacific Family Medicine 2014, 13:14 Page 3 of 9 http://www.apfmj.com/content/13/1/14 Methods approximately 470 km north of Metro Manila and access- This was a cross-sectional study conducted from October ible from there by air and land transportation. The LGHU 2010 to September 2011 involving people with diabetes has 2 health centers. Other health care services include a consulting at the purposively selected sites VMMC and tertiary-level Department of Health-operated hospital, LGHU of Batac City and Pagudpud. The main outcomes a primary-level private hospital, a number of private of interest were: diabetes knowledge, attitudes, percep- multi-specialty clinics and clinical laboratories, and sev- tions, self-care practices and patients? assessment of eral private drugstores/pharmacies. chronic illness care (PACIC) of the people with dia- Pagudpud (population 21,877 as of 2010 [20]), the betes in the two study settings. northernmost settlement in Luzon, is a rural municipal- ity classified to be very low in economic development. It The study sites is approximately 100 km further from Batac City. It only Family physician led-health service: the veterans health system has a basic government health unit health care. There The Veterans Memorial Medical Center (VMMC), located are no laboratory facilities, nor any private clinics or in Quezon City, Metro Manila, is the only health service drugstores/pharmacies. for Filipino veterans and their dependents in the whole All healthcare personnel of these LGHU come from country, to whom it delivers its free services. It is a 766- the same locality where they serve; the BHW come from bed multispecialty hospital where all levels of services the same village as the families they take care of. are confined in a single facility. First line health services For the people of Batac and Pagudpud, most health- are offered at the Department of Family Medicine and care expenditures are out-of-pocket and formal DSME/S Out-Patient Services where primary care is delivered by activities are non-existent in both the Batac City and family physicians organized as in a group practice; Pagudpud government health units. different clinical specialty services may also be availed of. Facilities that may deliver diabetes self-management Study participants education and support (DSME/S) are available, but there People with type 2 diabetes aged 20 years or more, con- are no formal DSME/S activities. sulting at the out-patient clinic of the VMMC or at the LGHU were invited for interview. Written informed Local government health units (LGHU): public health system consent was obtained from the respondents. Trained re- Public health care in the Philippines was devolved in searchers conducted one-on-one interviews making use 1992 and the responsibility of providing basic health of a structured questionnaire testing diabetes knowledge care services for the people was handed down to local and inquiring on attitudes, perceptions, PACIC, health- governments, specifically municipalities and cities, through seeking behavior and health care practices. their respective local government health units (LGHU) [18]. A decade before this health care devolution, the Diabetes knowledge country implemented a primary health care policy which A 24-item questionnaire on diabetes knowledge, answer- created a large cadre of community-based health workers able by yes, no, or I do not know, was prepared based locally called ? barangay health workers? (BHW) [19]. on the Fitzgerald et al. Brief Diabetes Knowledge Test Organizationally, the BHW fall under the governance of [21] and the Garcia et al. Diabetes Knowledge Question- the barangay (village) and are selected to work in their naire [22], adjusted to the local context with regard to respective areas of residence; functionally, they are under locally available medications and/or remedies, local food, the local government health units. A BHW is assigned and the local epidemiology of diabetes and its complica- approximately 10? 20 families and is responsible for dis- tions, taking into consideration local norms, customs, semination of health information and health promotion values, and traditions. Diabetes knowledge was measured activities, and conducts other health-related undertakings as the proportion of correct answers to the knowledge to any member of the families being attended to. The questionnaire. barangay is the smallest unit of government; a city or a municipality would be composed of a number of baran- Attitude and perceptions gays. At present, a typical LGHU would be composed of Questions on attitudes and perceptions were adapted from at least 1 health center and a number of barangay health the survey questionnaires of the University of Michigan stations, and would have at least one physician, usually Diabetes Research and Training Center [23,24]. The ques- a general practitioner/non-specialist, serving as munici- tions were formulated as statements to which answers pal/city health officer, at least one nurse and several made use of a 5-point Likert scale ranging from a lowest midwives, and the cadre of BHW. rating of 1 (strongly disagree/never) to a highest rating of Batac (population 53,542 as of 2010 [20]) is a non- 5 (strongly agree/always). Negative and positive attitudes highly urbanized component city in the island of Luzon were measured separately. We inquired into perceived Ku and Kegels Asia Pacific Family Medicine 2014, 13:14 Page 4 of 9 http://www.apfmj.com/content/13/1/14 needs for self-care support, support received, support combined and transformed to ? no/not fully adherent? . attitudes as well as perceptions related to the person? s Questions on exercise asked on the type, frequency, and ability to perform self-care, namely, to control blood duration of exercise done; the answers were then trans- glucose, control weight, do things needed for diabetes formed to ? no? or ? yes? based on the criteria of doing (diet, exercise, taking medications), and handle feelings 150 minutes of moderate-intensity aerobic physical ac- about diabetes. Questions on support needed and re- tivity or at least 75 minutes of vigorous-intensity aerobic ceived were directed towards support a person with physical activity throughout the week [26]. diabetes needs and receives from family and friends. Questions on support attitudes were about the percep- Statistical analysis tions of how a person with diabetes is being treated, Statistical analyses were done making use of the statis- accepted and supported by family and friends. The per- tical package Stata/IC version 11.0 [27]. ceived ability to perform self-care was equated to feelings Initial statistical analysis showed significant variations in of self-efficacy. Positive attitudes, negative attitudes, age and gender between the two groups and the potential perceived support needs, etc. were defined as a rating of of these factors as confounders; thus, data collected were more than 3. Perceived support received was said to be adjusted for age and gender based on the 2010 Philippine congruent to perceived support needs if the difference population [20] and Stata survey statistics were applied. between the former and the latter was 0; congruence <0 Differences in diabetes knowledge, positive and negative means that the perceived support received was less than attitudes, fear of diabetes, perceived support needs, per- the perceived needs while congruence >0 means that ceived support received, support attitudes, the perceptions support received was more than the perceived needs. of the abilities to perform self-care and the PACIC and its subscales according to the type of health service utilized Assessment of chronic illness care were tested using the regress command [28]. The two-way Glasgow?sPatient? s Assessment of Chronic Illness Care tabulate command, which makes use of Pearson?schi- (PACIC) was used [25]. The PACIC is a 20-item ques- square, was applied on the adjusted data to determine tionnaire making use of a 5-point Likert scale with 1 significant differences between the health services based (almost never) as the lowest and 5 (almost always) as the on proper utilization of health services and adherence to highest rating and where the questions can be grouped medications, diet and exercise [29]. together to form the subscales ? patient activation? , Logistic regression analysis was used to determine any ? delivery system design? , ? goal setting? , ? problem solving? , associations of the ratings of the PACIC and its subscales and ? follow-up/coordination? , which are linked to Wagner?s and knowledge, attitudes and perceptions rating; adher- chronic care model elements [3] and are related to the ence to medications, diet and exercise; and utilization of provision of collaborative care. Good ratings were de- health services. Level of education, known duration of the fined as a rating of more than 3. condition and the study settings were considered as add- itional potential confounders. Bivariate analysis was ini- Self-care practices tially done using a significance cut-off of 5%. Variables In this study, the questions on self-care practices re- fulfilling the criterion were then analyzed in multivariate ferred to health seeking behavior in terms of frequency logistic regression, with step-wise exclusion of variables of consultations done for diabetes, and adherence to having an alpha >0.05 to arrive at the final models. medications, diet and exercise. The question on consult- Cronbach? s alpha was used to measure the internal ation was about the number of times the person con- consistency/validity of the questions asked. sulted for diabetes with any formal health care provider in the past 6 months, and was stratified as none or once Results for the past 6 months (0-1/6 months) and 2 or more for A total of 549 respondents were interviewed: 350 from the past 6 months (≥2/6 months). The latter was inter- VMMC and 199 from the LGHU. Figure 1 shows the flow preted as the more adequate practice in this setting. of inclusion of the study participants and Table 1 lists Questions on medication adherence were about the some demographic characteristics of the respondents. medications as prescribed by care providers and if the Internal consistency/reliability of the knowledge, atti- respondents were taking the right medications at the tudes and perceptions (KAP) questions in this study popu- right dosages at the right times; these were answerable lation ranged from 0.72 to 0.94 [12]; it was 0.93 for the by ? no? or ? yes? and summarized as ? no? if any of the PACIC questions. questions were answered with ? no? and ? yes? if all the questions were answered with ? yes? . The question on Differences in KAP, PACIC and self-care practices diet adherence was answerable by ? no? , ? sometimes? ,or Table 2 lists the adjusted means and regress command ? yes/always? ; ? no? and ? sometimes? answers were later p values of the different variables comparing the two Ku and Kegels Asia Pacific Family Medicine 2014, 13:14 Page 5 of 9 http://www.apfmj.com/content/13/1/14 CONSIDERED FOR INTERVIEW=676 VMMC*=445 LGHU**=231 DID NOT FULFILL INCLUSION CRITERIA=80 VMMC=52 LGHU=28 INVITED FOR INTERVIEW=596 VMMC=393 LGHU=203 REFUSED=30 VMMC=26 LGHU=4 TOTAL INTERVIEWED=566 VMMC=367 LGHU=199 INCOMPLETE DATA=17 (all from VMMC) TOTAL INCLUDED IN DATA ANALYSIS=549 VMMC=350 LGHU=199 *VMMC ? Veterans Memorial Medical Center **LGHU ? local government health units Figure 1 Flow of recruitment and inclusion for interview and analysis. study settings. The differences in knowledge, attitudes, were significantly lower. Although the rating for perceived perceptions and self-care practices among people with support received was lower among those consulting at the diabetes consulting in the VMMC and the two LGHUs family physician-led health service, the rating for perceived have been presented and discussed in a previous publi- support needs was also lower; and congruence of the cation [12]. Among those consulting at the family support needs to the support received, although statisti- physician-led hospital health service, the age- and cally insignificant, was better. gender-adjusted ratings on the knowledge test, positive Age- and gender-adjusted total PACIC ratings were attitudes, perceived support attitudes and the perceived higher in the LGHU-based primary care services. Ana- abilities to perform self care/perceptions of self-efficacy lysis of the subscales of the PACIC shows that the ratings and the proportions of those properly utilizing health for ? problem solving? and ? follow-up and coordination? services and adherent to medications and exercise were were significantly higher among those consulting at the significantly higher and the ratings for negative attitudes LGHU. Table 1 Demographics of the respondents All VMMC LGHU Number of respondents, n (%) 549 350 (63.8%) 199 (36.2%) Gender (Male), n (%) 227 (41.4%) 176 (50.3%) 51 (25.6%) Age in years, mean (range) 62.8 (27 ? 92) 65.7 (33 ? 92) 57.6 (27 ? 90) Duration of diabetes in years, mean (range) 7.0 (0.5 ? 37) 8.3 (0.5 ? 37) 4.7 (0.5 ? 35) Education, n (%) 0-6 years 126 (23.0%) 69 (19.7%) 57 (28.6%) 7-10 years 219 (39.9%) 145 (41.4%) 74 (37.2%) >10 years 204 (37.1%) 136 (38.9%) 68 (34.2%) Ku and Kegels Asia Pacific Family Medicine 2014, 13:14 Page 6 of 9 http://www.apfmj.com/content/13/1/14 Table 2 Age- and gender-adjusted mean (95% confidence intervals) KAP and PACIC, and p values of the differences in KAP and PACIC of people with diabetes consulting at the family physician-led hospital-based (VMMC) vs. local government-based (LGHU) first line health services Factor VMMC LGHU P value (using regress command) Diabetes knowledge 70.7 (63.5-77.9) 58.7 (54.9-62.9) <0.001 Positive attitudes 3.7 (3.5-3.8) 3.3 (3.2-3.4) 0.002 Negative attitudes 2.2 (1.9-2.6) 3.1 (2.8-3.5) 0.001 Fear 2.6 (1.9-3.4) 3.5 (2.8-3.5) 0.076 Perceived support needs 2.7 (2.2-3.1) 4.3 (3.9-4.7) <0.001 Perceived support received 3.5 (3.1-4.0) 4.4 (4.2-4.6) <0.001 Congruence of perceived support received to 0.89 (0.18-1.61) 0.11 (−0.38-0.60) 0.095 perceived support needs Perceived support attitudes 5.0 (5.0-5.0) 4.6 (4.4-4.8) <0.001 Perceived ability to perform self-care/Perceptions Overall 3.7 (3.5-3.9) 3.2 (3.0-3.4) <0.001 of self-effciacy To control blood glucose 4.3 (4.1-4.5) 3.2 (2.8-3.6) <0.001 To control weight 4.3 (4.1-4.5) 3.5 (3.2-3.8) <0.001 To do things needed to be 4.1 (3.8-4.3) 3.3 (3.0-3.6) <0.001 done for diabetes To handle feelings on diabetes 4.0 (3.8-4.3) 3.5 (3.2-3.8) 0.030 Patients? assessment of chronic illness care Summary of overall score 2.6 (2.1-3.2) 3.2 (3.1-3.3) 0.016 Patient activation 2.6 (1.6-3.6) 3.5 (3.4-3.7) 0.086 Delivery system design 3.3 (2.5-4.0) 3.6 (3.4-3.8) 0.465 Goal setting 2.6 (2.0-3.2) 3.1 (3.0-3.3) 0.064 Problem solving 3.0 (2.7-3.2) 3.3 (3.1-3.5) 0.042 Follow-up/coordination 2.1 (1.8-2.3) 3.0 (2.9-3.2) <0.001 The proportions of people with proper utilization of self-efficacy was identified to be associated with all four health services and adherence to medications and to exer- self-care practices with the final models? odds ratios and cise were bigger among those consulting at the VMMC p values of perceived self-efficacy as follows: utilization (Table 3). of health services OR = 1.784, p = 0.002; medication adherence OR = 1.611, p = 0.012; diet adherence OR = Associations between KAP, PACIC, perceived self-efficacy 2.015, p < 0.001; and exercise adherence OR = 1.635, & self-care practices p = 0.001. Analysis of possible associations of self-care practices Logistic regression analysis of perceived self-efficacy with the PACIC and subscales ratings showed a signifi- showed positive association with the PACIC summary cant positive association between the PACIC summary (OR = 1.8798; p < 0.001) and the subscale ? patient activa- score rating and medication adherence (OR = 1.5185, tion? ratings (OR = 1.777; p < 0.001); while positive asso- p = 0.030); and a positive association between the PACIC ciations with the setting VMMC (OR = 3.823, p < 0.001), subscale ? delivery system design? and diet adherence diabetes knowledge (OR = 4.258; p = 0.025) and positive (OR = 1.3650, p = 0.022). In the earlier study [12], perceived attitudes (OR = 1.747;p = 0.001) were identified in the earlier study [12]. Table 3 Proportion of people with diabetes consulting at the health services with good self-care practices, adjusted Discussion to age and gender There were no existing formal diabetes self-management Self care practice VMMC LGHU P value (Pearson? s chi ) education and support activities in both family physician- Utilization of health services 78.8% 37.0% <0.001 led and local government-based health services at the time of this cross-sectional study. However, in general, family Adherence to medications 93.7% 52.4% <0.001 physicians practice active listening and counseling skills Adherence to diet 61.6% 47.9% 0.924 and patient-centered biopsychosocial approaches; other Adherence to exercise 66.1% 32.2% <0.001 health care personnel likewise conduct one-on-one and Ku and Kegels Asia Pacific Family Medicine 2014, 13:14 Page 7 of 9 http://www.apfmj.com/content/13/1/14 group health teachings to people consulting at the care practices, especially medication adherence as was VMMC. At the LGHU, physicians or nurses generally seen in this study. Interestingly, a higher PACIC summary conduct clinical consultations at the health centers while rating was likewise associated with medication adherence. BHW, and occasionally the midwives, follow-up through home visits of the families under their care. LGHU with culturally-competent healthcare workers This and the previous study conducted [12] have dem- PACIC ratings were higher among those consulting at onstrated that increased diabetes knowledge, positive at- the LGHU. It may be that respondents from the LGHU- titudes, the study setting VMMC, and higher PACIC based health services do not have high expectations or summary and the PACIC subscale ? patient activation? may not be knowledgeable enough to have such expecta- ratings are associated with higher levels of perceived tions form their health service, thus their higher PACIC self-efficacy. Perceived self-efficacy is positively associ- ratings. More than that, the socio-cultural homogeneity ated with all four self-care practices. Additionally, a of the health care workers serving people with diabetes higher PACIC summary rating is associated with adher- within their own communities in the LGHU-based health ence to medications while a higher rating for the PACIC service may have played a role especially because only the subscale ? delivery system design? is associated with diet subscales ? problem solving? and ? follow-up and coordin- adherence. People consulting at the study setting LGHU ation? were noted to have significantly higher ratings gave higher ratings for the PACIC and its subscales. among those consulting at the LGHU health services. With these, the specific characteristics of the two study Socio-cultural barriers exist in the family physician-led settings were analyzed further. health service as patients come from all over the country and, as is typical in group practices, may be seen by a Family medicine-led health service (VMMC) different health care worker each time they consult. It seems that the patient-centered, active listening-based, ? Problem solving? maybe viewedtobebetterifthe per- biopsychosocial approaches practiced by family physi- son with diabetes collaborates with a health care worker cians at the VMMC contribute to better knowledge, atti- without any socio-cultural barriers [34], which is the tudes and perceptions among people with diabetes case in the LGHUs. The perception of better ? follow-up [30,31] as was corroborated by this research. Diabetes and coordination? maybe enhancedbythe home visits self-care knowledge and skills development may be an done by the BHW. unmet need in non-patient-centered care settings [32]. Adopting self-care entails changes in behavior. Such be- Combining family medicine principles and cultural havior change should be understood as part of an interper- competence sonal process that may be enhanced by a collaborative, Although people consulting at the VMMC may have patient-centered approach and an effective and clear com- higher knowledge and perceived self-efficacy ratings, and munication process between the health care provider and perceived self-efficacy is positively associated with the the person with chronic condition [2]. This was demon- four self-care practices, two self-care practices were like- strated by a significantly higher perception of self-efficacy wise positively associated with the PACIC score; these and better self-care practices in terms of utilization of findings imply that certain qualities in both the Veterans health services, adherence to medications and adherence health system and the LGHU may contribute to the to exercise regimen among people consulting at the family adoption and adherence to self-care. physician-led health service. Furthermore, the active Ideally, self-management education and skills develop- listening and CEA approaches actually employed during ment should be carried out by a team of professionals, clinical consultations and in patient and family counseling which include primary care physicians, specialists, nurses, sessions may be useful in exploring and addressing the nutritionist/dietitians, psychologists [35]. However, such reasons behind why, how, and when people with chronic professional composition and creation of teams concen- conditions do not engage in adequate self-care. This may trating solely on chronic care delivery are not possible help eliminate environmental barriers such as conflicted across all areas in low- and middle-income countries family relationships, which have been shown to adversely (LMIC).AlthoughLMICs mayhavetertiarymedical affect self-care [33]. The better perception of support atti- services or referral centers where the abovementioned tudes of family and friends among those consulting at the resources are available, such health services, such as the family physician-led health service may connote to better VMMC in the Philippines, are mainly concentrated in resolution of identified family dysfunctions and patholo- urban areas. In a wider portion of these countries, gies as practiced in family medicine. Furthermore, the professional health care providers are limited to non- higher degree of support being offered at the VMMC in specialist physicians or nurses. Considering this context, terms of free medications and laboratory tests and the a collaborative biopsychosocial approach practiced by a availability of specialty services would favor better self- care provider having a similar socio-cultural background Ku and Kegels Asia Pacific Family Medicine 2014, 13:14 Page 8 of 9 http://www.apfmj.com/content/13/1/14 Figure 2 Theoretical framework: using culturally-competent, family medicine principles-basedchronic care delivery for self-care development. would be preferred to engage the person with chronic professionalism and cultural competence is instrumental conditions to adopt and adhere to self-care behavior. Such in promoting self-efficacy and adoption of adequate self- an approach is consistent with family medicine principles care behavior in people with diabetes. and is compatible with the current organization of LGHUs Abbreviations in the Philippines. However, in most cases, LGHU personnel, BHW: Barangay (village) health worker; CEA: Catharsis, education, action; from the physicians to the lay health care workers, do not DSME/S: Diabetes self-management education and support; KAP: Knowledge, attitudes and perceptions; LGHU: Local government health unit; possess the skills and training relevant to family medicine PACIC: Patients? Assessment Of Chronic Illness Care; VMMC: Veterans practices. This may be addressed by training LGHU staff Memorial Medical Center. on family medicine-based care such as patient-centered, Competing interests biopsychosocial approaches and the use of the CEA The authors declare that they have no competing interests. methods and active listening skills. Figure 2 proposes a theoretical framework on how combining culturally Authors? contributions GMVK contributed to the design of the research, participated in data competent health care with family medicine approaches collection, did the statistical analysis and drafted the manuscript. GK may increase self-efficacy and improve self-care behavior. provided substantial contributions in the concept and design, data analysis, and in the drafting of the manuscript. Both authors read and approved the final manuscript. Conclusions and recommendations This study has demonstrated that homogeneity in the Acknowledgements socio-cultural backgrounds of people with diabetes and We thank the Belgian Directorate for Development Cooperation through the Institute of Tropical Medicine, Antwerp for funding this research project. their health care providers seems to play an important This project was funded by the Belgian Directorate for Development role in the assessment of chronic illness care delivery Cooperation through the Institute of Tropical Medicine, Antwerp. while practicing a patient-centered, biopsychosocial Received: 13 December 2013 Accepted: 19 November 2014 approach, and active listening and counseling skills seems to result in better diabetes knowledge, improved attitudes, and better handling of familial psychodynam- References ics leading to better perceptions of self-efficacy and 1. 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Grundy J, Healy V, Gorgolon L, Sandig E: Overview of devolution of health services in the Philippines. Rural and Remote (online) 2003. http://www.rrh. org.au/articles/subviewnew.asp?ArticleID=220] 19. Philips DR: Primary healthcare in the Philippines: banking on the barangays? Soc Sci Med 1986, 23:1105? 1117. 20. Philippine National Statistics Office 2010 Census of Population and Housing: Total Population by Province, City, Municipality, and Barangay. Ilocos Norte; 2010 [http://www.nsoilocosnorte.com/View-file2.php] 21. Fitzgerald JT, Anderson RM, Funnell MM, Barr PA, Hiss RG, Hess GE, Davis WK: The reliability and validity of a brief diabetes knowledge test. Diabetes Care 1998, 21(5):706? 710. 22. Garcia AA, Villagomez ET, Brown SA, Kouzerkanani K, Hanes CL: The Starr county diabetes education study. Diabetes Care 2001, 24:16? 21. 23. Anderson RM, Fitzgerald JT, Funnell MM, Grupen LD: The third version of the Diabetes Attitude Scale (DAS-3). Diabetes Care 1998, 21:1403? 1407. 24. Fitzgerald JT, Davis WK, Connell CM, Hess GE, Funnell MM, Hiss RG: Development and validation of the diabetes care profile. Eval Health Prof 1996, 19:209? 231. 25. Glasgow RE, Whitesides H, Nelson CC, King DK: Use of the Patient Assessment of Chronic Illness Care (PACIC) with diabetic patients. Diabetes Care 2005, 28:2655? 2661. 26. World Health Organization: Global Recommendations on Physical Activity for Health. Geneva: WHO; 2010. Submit your next manuscript to BioMed Central 27. Stata/IC 11. Texas: StataCorp LP; 2009. 28. How can I do the T-test with survey data? [IDRE/UCLA http://www.ats. and take full advantage of: ucla.edu/stat/stata/faq/svyttest.htm] 29. Svy: tabulate two way ? Two way tables for survey data. [http://www. ? Convenient online submission stata.com/manuals13/svy.pdf] ? Thorough peer review 30. Woodcock JA, Kinmonth AL, Campbell MJ, Griffin SJ, Spiegal NM: Diabetes care from diagnosis: effects of training in patient-centered care on ? No space constraints or color ?gure charges beliefs, attitudes and behavior of primary care professionals. Patient Educ ? Immediate publication on acceptance Couns 1999, 37:65? 79. ? Inclusion in PubMed, CAS, Scopus and Google Scholar 31. Anderson RT, Balkrishnan R, Camacho F, Boll R, Duren-Winfield V, Goff D: Patient-centered outcomes of diabetes self-care: association with ? Research which is freely available for redistribution satisfaction and general health in a community clinic setting. N C Med J 2003, 64:58? 65. Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

A cross-sectional study of the differences in diabetes knowledge, attitudes, perceptions and self-care practices as related to assessment of chronic illness care among people with diabetes consulting in a family physician-led hospital-based first line health service and local government health unit-based health centers in the Philippines

Asia Pacific Family Medicine , Volume 13 (1) – Dec 16, 2014

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Copyright © 2014 by Ku and Kegels ; licensee BioMed Central.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1447-056X
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10.1186/s12930-014-0014-z
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25548539
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Abstract

Background: The purpose of this study was to investigate differences in diabetes knowledge, attitudes and perceptions (KAP), self-care practices as related to assessment of chronic illness care among people with diabetes consulting in a family physician-led tertiary hospital-based out-patient clinic versus local government health unit-based health centers in the Philippines. Methods: People with diabetes consulting in the said primary care services were interviewed making use of questionnaires adapted from previously tested and validated KAP questionnaires and the patients? assessment of chronic illness care (PACIC) questionnaire. Adherence to medications, diabetes diet, and exercise and the number of diabetes consultations were asked. Analysis of variance was used to determine differences in KAP, self-care practices, and PACIC and regression analysis was used to determine any associations of the abovementioned variables to the PACIC ratings. Results: A total of 549 respondents were included in the study. Differences in knowledge, attitudes, perceptions, PACIC, utilization of health services, and adherence to medications and exercise were all statistically significant. Ratings for diabetes knowledge, positive attitudes, and the perceptions of support attitudes and the abilities to perform self care, and the proportions of those properly utilizing health services and adhering to medications and exercise were higher while ratings for negative attitudes, perceived support needs, perceived support received and PACIC were lower among those consulting in the family physician-led health service. Conclusions: Combining family medicine-based approaches with culturally competent diabetes care may improve knowledge, attitudes, perceptions and self-care practices of and collaborative care with people with diabetes. Keywords: Biopsychosocial approach, Chronic conditions, Collaborative care, Culturally-competent care, Diabetes mellitus type 2, Family medicine principles, Perceived self-efficacy, Self-care development * Correspondence: gracemariekumd@yahoo.com Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium ? 2014 Ku and Kegels ; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ku and Kegels Asia Pacific Family Medicine 2014, 13:14 Page 2 of 9 http://www.apfmj.com/content/13/1/14 Introduction and support are provided by culturally competent care People with chronic conditions encounter many day- providers who engage these people in a collaborative to-day situations where they have to make decisions on manner using the biopsychosocial approach and family their own [1]; self-care plays an important role and medicine-based principles. collaboration rather than a health provider-directed This study compared the differences in on-going pri- care may be a more effective care model [2]. Collabora- mary diabetes care through assessments of chronic care tive care between people with chronic conditions and delivery between a family physician-led hospital-based their health care providers is better achieved if the health service where a biopsychosocial, collaborative ap- people having these chronic conditions are informed proach is practiced, and local government health units and activated [3]. Such may involve self-management edu- (LGHU) with community-based services where the care cation and skills development. However, the provision of providers and recipients of care have congruent socio- self-management education and support is not simple. cultural backgrounds, as related to diabetes knowledge, It does not only involve the development of self- attitudes, perceptions on family support, perceptions of management skills but barriers should also be addressed self-efficacy and self-care practices of people with dia- [4]. These barriers include personal, social and environ- betes utilizing these said services. mental barriers. Personal barriers include disease-related beliefs, emotions, knowledge and experiences [5]; socio- Background cultural barriers take account of the differences in lan- Family medicine in the Philippines guage, and in cultural and ethnic beliefs and perceptions Leopando and Olazo extensively discuss family medicine of health and illness [6] between the providers and the as a specialty in the Philippines [13]. A physician special- recipients of self-management development; and envir- izing in family medicine is seen as having the following onmental barriers refer to the immediate environment roles and responsibilities: health care provider, counselor, of family and friends and the wider environment of the administrator, teacher, social mobilizer and researcher. health care system and the community in supporting As a health care provider, the family physician assumes adoption of proper self-care behavior. Studies have dem- the roles of gatekeeper, primary care giver, hospice care onstrated that culturally competent self-management giver and family health care giver. As a counselor, the education improved diabetes care, self-awareness and family physician is expected to practice active listening understanding of diabetes [7] while patient-centered, skills [14] and the CEA (Catharsis, Education, Action) biopsychosocial approaches as practiced in the family methods [15]. As administrator, the family physician medicine paradigm address personal barriers [8] and takes on the roles of a coordinator and manager who improved diabetes knowledge, patient perceived self- integrates and coordinates health services for the pa- efficacy and glycemia [9-11]. tients and their families. As a teacher/educator, the It should be noted that self-management skills devel- family physician assumes the roles of trainer and health opment are usually given as part of the clinical care promoter providing education and skills development in delivered by care providers; and the background, methods, family medicine and public health. As a social mobilizer, settings, and context by which self-management education the family physician is a health advocate and a commu- and support is to be introduced and delivered should be nity health organizer promoting wellness and health optimized to ensure maximum absorption and adoption maintenance to individuals, families and the public, and of self-care behavior. In settings where such self-care empowers patients towards self-care. As a researcher, development activities are non-existent, establishing the family physician produces relevant and evidence-based current status of diabetes care and its effects on factors research outputs. Some family medicine practices are that may affect self-care is needed to prepare these health hospital-based while others are in health centers in the services in the delivery of self-management education and communities. In both settings, family medicine-based first support. line and ambulatory care services can be delivered. In an earlier publication, the investigators constructed Family medicine training in the Philippines is thus a framework for self-management education and support geared towards producing family physicians who can ful- wherein perceived self-efficacy of the person with chronic fill these roles and responsibilities. Central to this would condition plays a vital role in the adoption and adherence be training not only in the provision of biomedical care of proper self-care behavior; this perception of self-efficacy but also taking into consideration various psychosocial may be affected by internal and external influences [12]. factors that may positively or negatively affect the course In here, the investigators theorize that healthcare pro- of illness and how the person will participate in self- viders may positively influence people with chronic care. Training healthcare providers who are responsible conditions to perceive a higher degree of self-efficacy for primary care on the biopsychosocial approach has and to carry out self-care practices better if education long been advocated [16,17]. Ku and Kegels Asia Pacific Family Medicine 2014, 13:14 Page 3 of 9 http://www.apfmj.com/content/13/1/14 Methods approximately 470 km north of Metro Manila and access- This was a cross-sectional study conducted from October ible from there by air and land transportation. The LGHU 2010 to September 2011 involving people with diabetes has 2 health centers. Other health care services include a consulting at the purposively selected sites VMMC and tertiary-level Department of Health-operated hospital, LGHU of Batac City and Pagudpud. The main outcomes a primary-level private hospital, a number of private of interest were: diabetes knowledge, attitudes, percep- multi-specialty clinics and clinical laboratories, and sev- tions, self-care practices and patients? assessment of eral private drugstores/pharmacies. chronic illness care (PACIC) of the people with dia- Pagudpud (population 21,877 as of 2010 [20]), the betes in the two study settings. northernmost settlement in Luzon, is a rural municipal- ity classified to be very low in economic development. It The study sites is approximately 100 km further from Batac City. It only Family physician led-health service: the veterans health system has a basic government health unit health care. There The Veterans Memorial Medical Center (VMMC), located are no laboratory facilities, nor any private clinics or in Quezon City, Metro Manila, is the only health service drugstores/pharmacies. for Filipino veterans and their dependents in the whole All healthcare personnel of these LGHU come from country, to whom it delivers its free services. It is a 766- the same locality where they serve; the BHW come from bed multispecialty hospital where all levels of services the same village as the families they take care of. are confined in a single facility. First line health services For the people of Batac and Pagudpud, most health- are offered at the Department of Family Medicine and care expenditures are out-of-pocket and formal DSME/S Out-Patient Services where primary care is delivered by activities are non-existent in both the Batac City and family physicians organized as in a group practice; Pagudpud government health units. different clinical specialty services may also be availed of. Facilities that may deliver diabetes self-management Study participants education and support (DSME/S) are available, but there People with type 2 diabetes aged 20 years or more, con- are no formal DSME/S activities. sulting at the out-patient clinic of the VMMC or at the LGHU were invited for interview. Written informed Local government health units (LGHU): public health system consent was obtained from the respondents. Trained re- Public health care in the Philippines was devolved in searchers conducted one-on-one interviews making use 1992 and the responsibility of providing basic health of a structured questionnaire testing diabetes knowledge care services for the people was handed down to local and inquiring on attitudes, perceptions, PACIC, health- governments, specifically municipalities and cities, through seeking behavior and health care practices. their respective local government health units (LGHU) [18]. A decade before this health care devolution, the Diabetes knowledge country implemented a primary health care policy which A 24-item questionnaire on diabetes knowledge, answer- created a large cadre of community-based health workers able by yes, no, or I do not know, was prepared based locally called ? barangay health workers? (BHW) [19]. on the Fitzgerald et al. Brief Diabetes Knowledge Test Organizationally, the BHW fall under the governance of [21] and the Garcia et al. Diabetes Knowledge Question- the barangay (village) and are selected to work in their naire [22], adjusted to the local context with regard to respective areas of residence; functionally, they are under locally available medications and/or remedies, local food, the local government health units. A BHW is assigned and the local epidemiology of diabetes and its complica- approximately 10? 20 families and is responsible for dis- tions, taking into consideration local norms, customs, semination of health information and health promotion values, and traditions. Diabetes knowledge was measured activities, and conducts other health-related undertakings as the proportion of correct answers to the knowledge to any member of the families being attended to. The questionnaire. barangay is the smallest unit of government; a city or a municipality would be composed of a number of baran- Attitude and perceptions gays. At present, a typical LGHU would be composed of Questions on attitudes and perceptions were adapted from at least 1 health center and a number of barangay health the survey questionnaires of the University of Michigan stations, and would have at least one physician, usually Diabetes Research and Training Center [23,24]. The ques- a general practitioner/non-specialist, serving as munici- tions were formulated as statements to which answers pal/city health officer, at least one nurse and several made use of a 5-point Likert scale ranging from a lowest midwives, and the cadre of BHW. rating of 1 (strongly disagree/never) to a highest rating of Batac (population 53,542 as of 2010 [20]) is a non- 5 (strongly agree/always). Negative and positive attitudes highly urbanized component city in the island of Luzon were measured separately. We inquired into perceived Ku and Kegels Asia Pacific Family Medicine 2014, 13:14 Page 4 of 9 http://www.apfmj.com/content/13/1/14 needs for self-care support, support received, support combined and transformed to ? no/not fully adherent? . attitudes as well as perceptions related to the person? s Questions on exercise asked on the type, frequency, and ability to perform self-care, namely, to control blood duration of exercise done; the answers were then trans- glucose, control weight, do things needed for diabetes formed to ? no? or ? yes? based on the criteria of doing (diet, exercise, taking medications), and handle feelings 150 minutes of moderate-intensity aerobic physical ac- about diabetes. Questions on support needed and re- tivity or at least 75 minutes of vigorous-intensity aerobic ceived were directed towards support a person with physical activity throughout the week [26]. diabetes needs and receives from family and friends. Questions on support attitudes were about the percep- Statistical analysis tions of how a person with diabetes is being treated, Statistical analyses were done making use of the statis- accepted and supported by family and friends. The per- tical package Stata/IC version 11.0 [27]. ceived ability to perform self-care was equated to feelings Initial statistical analysis showed significant variations in of self-efficacy. Positive attitudes, negative attitudes, age and gender between the two groups and the potential perceived support needs, etc. were defined as a rating of of these factors as confounders; thus, data collected were more than 3. Perceived support received was said to be adjusted for age and gender based on the 2010 Philippine congruent to perceived support needs if the difference population [20] and Stata survey statistics were applied. between the former and the latter was 0; congruence <0 Differences in diabetes knowledge, positive and negative means that the perceived support received was less than attitudes, fear of diabetes, perceived support needs, per- the perceived needs while congruence >0 means that ceived support received, support attitudes, the perceptions support received was more than the perceived needs. of the abilities to perform self-care and the PACIC and its subscales according to the type of health service utilized Assessment of chronic illness care were tested using the regress command [28]. The two-way Glasgow?sPatient? s Assessment of Chronic Illness Care tabulate command, which makes use of Pearson?schi- (PACIC) was used [25]. The PACIC is a 20-item ques- square, was applied on the adjusted data to determine tionnaire making use of a 5-point Likert scale with 1 significant differences between the health services based (almost never) as the lowest and 5 (almost always) as the on proper utilization of health services and adherence to highest rating and where the questions can be grouped medications, diet and exercise [29]. together to form the subscales ? patient activation? , Logistic regression analysis was used to determine any ? delivery system design? , ? goal setting? , ? problem solving? , associations of the ratings of the PACIC and its subscales and ? follow-up/coordination? , which are linked to Wagner?s and knowledge, attitudes and perceptions rating; adher- chronic care model elements [3] and are related to the ence to medications, diet and exercise; and utilization of provision of collaborative care. Good ratings were de- health services. Level of education, known duration of the fined as a rating of more than 3. condition and the study settings were considered as add- itional potential confounders. Bivariate analysis was ini- Self-care practices tially done using a significance cut-off of 5%. Variables In this study, the questions on self-care practices re- fulfilling the criterion were then analyzed in multivariate ferred to health seeking behavior in terms of frequency logistic regression, with step-wise exclusion of variables of consultations done for diabetes, and adherence to having an alpha >0.05 to arrive at the final models. medications, diet and exercise. The question on consult- Cronbach? s alpha was used to measure the internal ation was about the number of times the person con- consistency/validity of the questions asked. sulted for diabetes with any formal health care provider in the past 6 months, and was stratified as none or once Results for the past 6 months (0-1/6 months) and 2 or more for A total of 549 respondents were interviewed: 350 from the past 6 months (≥2/6 months). The latter was inter- VMMC and 199 from the LGHU. Figure 1 shows the flow preted as the more adequate practice in this setting. of inclusion of the study participants and Table 1 lists Questions on medication adherence were about the some demographic characteristics of the respondents. medications as prescribed by care providers and if the Internal consistency/reliability of the knowledge, atti- respondents were taking the right medications at the tudes and perceptions (KAP) questions in this study popu- right dosages at the right times; these were answerable lation ranged from 0.72 to 0.94 [12]; it was 0.93 for the by ? no? or ? yes? and summarized as ? no? if any of the PACIC questions. questions were answered with ? no? and ? yes? if all the questions were answered with ? yes? . The question on Differences in KAP, PACIC and self-care practices diet adherence was answerable by ? no? , ? sometimes? ,or Table 2 lists the adjusted means and regress command ? yes/always? ; ? no? and ? sometimes? answers were later p values of the different variables comparing the two Ku and Kegels Asia Pacific Family Medicine 2014, 13:14 Page 5 of 9 http://www.apfmj.com/content/13/1/14 CONSIDERED FOR INTERVIEW=676 VMMC*=445 LGHU**=231 DID NOT FULFILL INCLUSION CRITERIA=80 VMMC=52 LGHU=28 INVITED FOR INTERVIEW=596 VMMC=393 LGHU=203 REFUSED=30 VMMC=26 LGHU=4 TOTAL INTERVIEWED=566 VMMC=367 LGHU=199 INCOMPLETE DATA=17 (all from VMMC) TOTAL INCLUDED IN DATA ANALYSIS=549 VMMC=350 LGHU=199 *VMMC ? Veterans Memorial Medical Center **LGHU ? local government health units Figure 1 Flow of recruitment and inclusion for interview and analysis. study settings. The differences in knowledge, attitudes, were significantly lower. Although the rating for perceived perceptions and self-care practices among people with support received was lower among those consulting at the diabetes consulting in the VMMC and the two LGHUs family physician-led health service, the rating for perceived have been presented and discussed in a previous publi- support needs was also lower; and congruence of the cation [12]. Among those consulting at the family support needs to the support received, although statisti- physician-led hospital health service, the age- and cally insignificant, was better. gender-adjusted ratings on the knowledge test, positive Age- and gender-adjusted total PACIC ratings were attitudes, perceived support attitudes and the perceived higher in the LGHU-based primary care services. Ana- abilities to perform self care/perceptions of self-efficacy lysis of the subscales of the PACIC shows that the ratings and the proportions of those properly utilizing health for ? problem solving? and ? follow-up and coordination? services and adherent to medications and exercise were were significantly higher among those consulting at the significantly higher and the ratings for negative attitudes LGHU. Table 1 Demographics of the respondents All VMMC LGHU Number of respondents, n (%) 549 350 (63.8%) 199 (36.2%) Gender (Male), n (%) 227 (41.4%) 176 (50.3%) 51 (25.6%) Age in years, mean (range) 62.8 (27 ? 92) 65.7 (33 ? 92) 57.6 (27 ? 90) Duration of diabetes in years, mean (range) 7.0 (0.5 ? 37) 8.3 (0.5 ? 37) 4.7 (0.5 ? 35) Education, n (%) 0-6 years 126 (23.0%) 69 (19.7%) 57 (28.6%) 7-10 years 219 (39.9%) 145 (41.4%) 74 (37.2%) >10 years 204 (37.1%) 136 (38.9%) 68 (34.2%) Ku and Kegels Asia Pacific Family Medicine 2014, 13:14 Page 6 of 9 http://www.apfmj.com/content/13/1/14 Table 2 Age- and gender-adjusted mean (95% confidence intervals) KAP and PACIC, and p values of the differences in KAP and PACIC of people with diabetes consulting at the family physician-led hospital-based (VMMC) vs. local government-based (LGHU) first line health services Factor VMMC LGHU P value (using regress command) Diabetes knowledge 70.7 (63.5-77.9) 58.7 (54.9-62.9) <0.001 Positive attitudes 3.7 (3.5-3.8) 3.3 (3.2-3.4) 0.002 Negative attitudes 2.2 (1.9-2.6) 3.1 (2.8-3.5) 0.001 Fear 2.6 (1.9-3.4) 3.5 (2.8-3.5) 0.076 Perceived support needs 2.7 (2.2-3.1) 4.3 (3.9-4.7) <0.001 Perceived support received 3.5 (3.1-4.0) 4.4 (4.2-4.6) <0.001 Congruence of perceived support received to 0.89 (0.18-1.61) 0.11 (−0.38-0.60) 0.095 perceived support needs Perceived support attitudes 5.0 (5.0-5.0) 4.6 (4.4-4.8) <0.001 Perceived ability to perform self-care/Perceptions Overall 3.7 (3.5-3.9) 3.2 (3.0-3.4) <0.001 of self-effciacy To control blood glucose 4.3 (4.1-4.5) 3.2 (2.8-3.6) <0.001 To control weight 4.3 (4.1-4.5) 3.5 (3.2-3.8) <0.001 To do things needed to be 4.1 (3.8-4.3) 3.3 (3.0-3.6) <0.001 done for diabetes To handle feelings on diabetes 4.0 (3.8-4.3) 3.5 (3.2-3.8) 0.030 Patients? assessment of chronic illness care Summary of overall score 2.6 (2.1-3.2) 3.2 (3.1-3.3) 0.016 Patient activation 2.6 (1.6-3.6) 3.5 (3.4-3.7) 0.086 Delivery system design 3.3 (2.5-4.0) 3.6 (3.4-3.8) 0.465 Goal setting 2.6 (2.0-3.2) 3.1 (3.0-3.3) 0.064 Problem solving 3.0 (2.7-3.2) 3.3 (3.1-3.5) 0.042 Follow-up/coordination 2.1 (1.8-2.3) 3.0 (2.9-3.2) <0.001 The proportions of people with proper utilization of self-efficacy was identified to be associated with all four health services and adherence to medications and to exer- self-care practices with the final models? odds ratios and cise were bigger among those consulting at the VMMC p values of perceived self-efficacy as follows: utilization (Table 3). of health services OR = 1.784, p = 0.002; medication adherence OR = 1.611, p = 0.012; diet adherence OR = Associations between KAP, PACIC, perceived self-efficacy 2.015, p < 0.001; and exercise adherence OR = 1.635, & self-care practices p = 0.001. Analysis of possible associations of self-care practices Logistic regression analysis of perceived self-efficacy with the PACIC and subscales ratings showed a signifi- showed positive association with the PACIC summary cant positive association between the PACIC summary (OR = 1.8798; p < 0.001) and the subscale ? patient activa- score rating and medication adherence (OR = 1.5185, tion? ratings (OR = 1.777; p < 0.001); while positive asso- p = 0.030); and a positive association between the PACIC ciations with the setting VMMC (OR = 3.823, p < 0.001), subscale ? delivery system design? and diet adherence diabetes knowledge (OR = 4.258; p = 0.025) and positive (OR = 1.3650, p = 0.022). In the earlier study [12], perceived attitudes (OR = 1.747;p = 0.001) were identified in the earlier study [12]. Table 3 Proportion of people with diabetes consulting at the health services with good self-care practices, adjusted Discussion to age and gender There were no existing formal diabetes self-management Self care practice VMMC LGHU P value (Pearson? s chi ) education and support activities in both family physician- Utilization of health services 78.8% 37.0% <0.001 led and local government-based health services at the time of this cross-sectional study. However, in general, family Adherence to medications 93.7% 52.4% <0.001 physicians practice active listening and counseling skills Adherence to diet 61.6% 47.9% 0.924 and patient-centered biopsychosocial approaches; other Adherence to exercise 66.1% 32.2% <0.001 health care personnel likewise conduct one-on-one and Ku and Kegels Asia Pacific Family Medicine 2014, 13:14 Page 7 of 9 http://www.apfmj.com/content/13/1/14 group health teachings to people consulting at the care practices, especially medication adherence as was VMMC. At the LGHU, physicians or nurses generally seen in this study. Interestingly, a higher PACIC summary conduct clinical consultations at the health centers while rating was likewise associated with medication adherence. BHW, and occasionally the midwives, follow-up through home visits of the families under their care. LGHU with culturally-competent healthcare workers This and the previous study conducted [12] have dem- PACIC ratings were higher among those consulting at onstrated that increased diabetes knowledge, positive at- the LGHU. It may be that respondents from the LGHU- titudes, the study setting VMMC, and higher PACIC based health services do not have high expectations or summary and the PACIC subscale ? patient activation? may not be knowledgeable enough to have such expecta- ratings are associated with higher levels of perceived tions form their health service, thus their higher PACIC self-efficacy. Perceived self-efficacy is positively associ- ratings. More than that, the socio-cultural homogeneity ated with all four self-care practices. Additionally, a of the health care workers serving people with diabetes higher PACIC summary rating is associated with adher- within their own communities in the LGHU-based health ence to medications while a higher rating for the PACIC service may have played a role especially because only the subscale ? delivery system design? is associated with diet subscales ? problem solving? and ? follow-up and coordin- adherence. People consulting at the study setting LGHU ation? were noted to have significantly higher ratings gave higher ratings for the PACIC and its subscales. among those consulting at the LGHU health services. With these, the specific characteristics of the two study Socio-cultural barriers exist in the family physician-led settings were analyzed further. health service as patients come from all over the country and, as is typical in group practices, may be seen by a Family medicine-led health service (VMMC) different health care worker each time they consult. It seems that the patient-centered, active listening-based, ? Problem solving? maybe viewedtobebetterifthe per- biopsychosocial approaches practiced by family physi- son with diabetes collaborates with a health care worker cians at the VMMC contribute to better knowledge, atti- without any socio-cultural barriers [34], which is the tudes and perceptions among people with diabetes case in the LGHUs. The perception of better ? follow-up [30,31] as was corroborated by this research. Diabetes and coordination? maybe enhancedbythe home visits self-care knowledge and skills development may be an done by the BHW. unmet need in non-patient-centered care settings [32]. Adopting self-care entails changes in behavior. Such be- Combining family medicine principles and cultural havior change should be understood as part of an interper- competence sonal process that may be enhanced by a collaborative, Although people consulting at the VMMC may have patient-centered approach and an effective and clear com- higher knowledge and perceived self-efficacy ratings, and munication process between the health care provider and perceived self-efficacy is positively associated with the the person with chronic condition [2]. This was demon- four self-care practices, two self-care practices were like- strated by a significantly higher perception of self-efficacy wise positively associated with the PACIC score; these and better self-care practices in terms of utilization of findings imply that certain qualities in both the Veterans health services, adherence to medications and adherence health system and the LGHU may contribute to the to exercise regimen among people consulting at the family adoption and adherence to self-care. physician-led health service. Furthermore, the active Ideally, self-management education and skills develop- listening and CEA approaches actually employed during ment should be carried out by a team of professionals, clinical consultations and in patient and family counseling which include primary care physicians, specialists, nurses, sessions may be useful in exploring and addressing the nutritionist/dietitians, psychologists [35]. However, such reasons behind why, how, and when people with chronic professional composition and creation of teams concen- conditions do not engage in adequate self-care. This may trating solely on chronic care delivery are not possible help eliminate environmental barriers such as conflicted across all areas in low- and middle-income countries family relationships, which have been shown to adversely (LMIC).AlthoughLMICs mayhavetertiarymedical affect self-care [33]. The better perception of support atti- services or referral centers where the abovementioned tudes of family and friends among those consulting at the resources are available, such health services, such as the family physician-led health service may connote to better VMMC in the Philippines, are mainly concentrated in resolution of identified family dysfunctions and patholo- urban areas. In a wider portion of these countries, gies as practiced in family medicine. Furthermore, the professional health care providers are limited to non- higher degree of support being offered at the VMMC in specialist physicians or nurses. Considering this context, terms of free medications and laboratory tests and the a collaborative biopsychosocial approach practiced by a availability of specialty services would favor better self- care provider having a similar socio-cultural background Ku and Kegels Asia Pacific Family Medicine 2014, 13:14 Page 8 of 9 http://www.apfmj.com/content/13/1/14 Figure 2 Theoretical framework: using culturally-competent, family medicine principles-basedchronic care delivery for self-care development. would be preferred to engage the person with chronic professionalism and cultural competence is instrumental conditions to adopt and adhere to self-care behavior. Such in promoting self-efficacy and adoption of adequate self- an approach is consistent with family medicine principles care behavior in people with diabetes. and is compatible with the current organization of LGHUs Abbreviations in the Philippines. However, in most cases, LGHU personnel, BHW: Barangay (village) health worker; CEA: Catharsis, education, action; from the physicians to the lay health care workers, do not DSME/S: Diabetes self-management education and support; KAP: Knowledge, attitudes and perceptions; LGHU: Local government health unit; possess the skills and training relevant to family medicine PACIC: Patients? Assessment Of Chronic Illness Care; VMMC: Veterans practices. This may be addressed by training LGHU staff Memorial Medical Center. on family medicine-based care such as patient-centered, Competing interests biopsychosocial approaches and the use of the CEA The authors declare that they have no competing interests. methods and active listening skills. Figure 2 proposes a theoretical framework on how combining culturally Authors? contributions GMVK contributed to the design of the research, participated in data competent health care with family medicine approaches collection, did the statistical analysis and drafted the manuscript. GK may increase self-efficacy and improve self-care behavior. provided substantial contributions in the concept and design, data analysis, and in the drafting of the manuscript. Both authors read and approved the final manuscript. Conclusions and recommendations This study has demonstrated that homogeneity in the Acknowledgements socio-cultural backgrounds of people with diabetes and We thank the Belgian Directorate for Development Cooperation through the Institute of Tropical Medicine, Antwerp for funding this research project. their health care providers seems to play an important This project was funded by the Belgian Directorate for Development role in the assessment of chronic illness care delivery Cooperation through the Institute of Tropical Medicine, Antwerp. while practicing a patient-centered, biopsychosocial Received: 13 December 2013 Accepted: 19 November 2014 approach, and active listening and counseling skills seems to result in better diabetes knowledge, improved attitudes, and better handling of familial psychodynam- References ics leading to better perceptions of self-efficacy and 1. 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Asia Pacific Family MedicineSpringer Journals

Published: Dec 16, 2014

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