Transcript OPrac 4 - Global Knowledge

PERSPECTIVES OF PHARMACISTS IN THEIR
ROLE IN TYPE 2 DIABETES MANAGEMENT: A
QUALITATIVE STUDY
M. A. Salmiah1, C. Anderson2, Nor Azmi K.3
1
University Technology MARA, Shah Alam, MALAYSIA
2 University of Nottingham, Nottingham, UNITED KINGDOM
3 National University of Malaysia, Kuala Lumpur, MALAYSIA
1
INTRODUCTION
• Countries all over the world are concerned with the high
prevalence of diabetes.
• 150 million people worldwide (6% of world population)
• WHO estimated the number will increase to 350 million
by year 20251 (Cockram, 2000a).
INTRODUCTION
OBJECTIVES
METHODOLOGY
METHOD
DATA COLLECTION
ANALYSIS
FINDINGS
RECOMMENDATION
CONCLUSION
REFERENCES
• Expenditure worldwide is estimated to be US$ 213
billion and US$ 396 billion by year 2025 2
(International Diabetes Federation report, 2003).
• 75% of these estimates are expected to be from
developing countries 3, 4 (Ma et al, 2003 and Chuang et
al, 2002).
• With this scenario, diabetes will burden the health care
system, with other chronic diseases such as coronary
heart disease, asthma, hypertension, and kidney failure
5(Lawton, et al, 2005a).
2
INTRODUCTION (cont.,)
• Adequate blood glucose control is vital in
diabetes
management
to
prevent
complications. Yet, despite the various
interventions, diabetes control remains a global
problem to health care professionals (HCPs).
INTRODUCTION
OBJECTIVES
METHODOLOGY
METHOD
DATA COLLECTION
ANALYSIS
FINDINGS
RECOMMENDATION
CONCLUSION
REFERENCES
• Diabetes poses a major threat to this
phenomenon as more people suffer from
diabetes due to the increase in the level of
obesity worldwide;
– uncontrolled diabetes has led to an increase in
complications
– has doubled the cost of treating these patients.
• Complications of diabetes have caused
Malaysia to be ranked as number one in kidney
failure due to diabetes6.
3
INTRODUCTION (cont.,)
• With the growing number of people
diagnosed with diabetes, there is a need
to understand why the lack of control
among diabetes in Malaysia.
INTRODUCTION
OBJECTIVES
METHODOLOGY
METHOD
DATA COLLECTION
ANALYSIS
• Agarwal et al, (2002)7 - stressed that
giving out new medical information was
found to be minimally effective in
changing practice behaviours regarding
diabetes but education which addresses
attitudes and knowledge is more
effective in improving diabetic outcomes.
FINDINGS
RECOMMENDATION
CONCLUSION
REFERENCES
• Qualitative research on chronic illness.84
OBJECTIVES
INTRODUCTION
OBJECTIVES
METHODOLOGY
METHOD
DATA COLLECTION
ANALYSIS
FINDINGS
1. Understand qualitative research
method.
2. Explore patients’ use of medicines
and adherence in managing
chronic illness in Malay patients
with Type 2 diabetes.
3. Perspectives and experiences of
pharmacists in managing chronic
illness of Type 2 diabetes.
RECOMMENDATION
CONCLUSION
REFERENCES
5
METHODOLOGY
Qualitative research:
• allows understanding of patients’ experiences,
their knowledge and coping strategies.
INTRODUCTION
OBJECTIVES
METHODOLOGY
METHOD
DATA COLLECTION
ANALYSIS
• ensures understanding of the problems that
quantitative research is unable to uncover and
to enhance a more complete scenario in the
research field.
• methods are used in health research to
understand each patient as an individual who
requires a consulting strategy that is appropriate
to his or her unique needs.
FINDINGS
RECOMMENDATION
CONCLUSION
REFERENCES
6
METHODOLOGY (cont.,)
Why do qualitative research?
• “… It should begin to close the gap between the
sciences of discovery and implementation.”
(Jones 1995).
• Qualitative method allows researcher to attend
closely to what happened in the empirical world
in the study.
INTRODUCTION
OBJECTIVES
METHODOLOGY
METHOD
DATA COLLECTION
ANALYSIS
FINDINGS
RECOMMENDATION
CONCLUSION
REFERENCES
• E.g. studies of people with chronic illness:
– with an interest in how they experienced
time,
– illness affected them,
– self concept,
– identity and duration of the study,
– problems of disclosing illness how, when,
why ill people talked about their conditions. 7
METHOD
• In-depth interviews were carried out
using
a
purposeful
sampling
participants.
INTRODUCTION
OBJECTIVES
METHODOLOGY
METHOD
DATA COLLECTION
ANALYSIS
FINDINGS
• Theoretical sampling of grounded
theory was used to determined the
participants of 18 Malay patients (age
range= 15-75 years; male= 9; female=
9) in Endocrinology Clinic in Malaysia.
• 13 health care professionals (HCPs)
were interviewed.
RECOMMENDATION
CONCLUSION
REFERENCES
8
METHOD
INTRODUCTION
OBJECTIVES
METHODOLOGY
METHOD
DATA COLLECTION
ANALYSIS
• Computer Aided Qualitative Data Analysis
Software (CAQDAS) NVivo v.2 was used to
enhance data management and analysis.
• The transcribed interviews were subjected to
grounded theory (thematic) analysis.
• Using NVivo - transcribed audiotapes were
analysed to identify emerging themes, then
coded according to categories.
• Issues raised during interviews were identified
as contributory factors to non-adherence to
diabetes treatment.
FINDINGS
RECOMMENDATION
CONCLUSION
REFERENCES
9
DATA COLLECTION AND
ANALYSIS
•
•
INTRODUCTION
OBJECTIVES
•
In-depth interviews using semi-structured
interview guides were used to gather data for
the project.
These interviews were recorded (with
respondents consent) using audiotapes and
transcribed for data analysis.
This involved:
–
METHODOLOGY
METHOD
DATA COLLECTION
ANALYSIS
FINDINGS
–
–
Developing codes, categories, and themes on the
data
Generating hypothesis or proposal from the data,
Analysing narratives of participants’ experiences
with their diabetic patients’ illness and coping with
their treatment regimen.
RECOMMENDATION
CONCLUSION
REFERENCES
10
FINDINGS
•
Themes that emerged from interviews with
pharmacists found that patients:
 faced problems in integrating their
treatment regimen to achieve the desired
blood glucose level.
INTRODUCTION
OBJECTIVES
METHODOLOGY
METHOD
DATA COLLECTION
ANALYSIS
FINDINGS
RECOMMENDATION
CONCLUSION
REFERENCES
 lacked knowledge about their medicines,
dietary
control,
medicine
taking,
complexities of treatment, and side effects
of medications.
 fail to integrate treatment regimen which
could lead to uncontrolled diabetes.
11
PHARMACISTS’
PERSPECTIVES
1) Patients lack dietary control
and understanding of sugarless
diet.
INTRODUCTION
OBJECTIVES
METHODOLOGY
METHOD
DATA COLLECTION
ANALYSIS
FINDINGS
RECOMMENDATION
Diet was difficult to control among
Malay patients due to demands
made by their family members. As
H12 explained,
CONCLUSION
REFERENCES
12
PHARMACISTS’ PERSPECTIVES
So what is the reason
for this? Especially
with Malay family?
SMA
It is a vicious circle…they always
have “kenduri”, their families
come back… their children come
back and they have to cook.
H12
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PHARMACISTS’ PERSPECTIVES
2) Patients attitude towards diabetes
–
–
H11 stressed the importance of patients’ ‘education
level’ to understand the disease and added that
patients believed diabetes could be cured and they
also thought that they could eat anything if they took
their insulin.
Patients’ mistaken belief that their condition has
been cured should also be addressed 9(Parry et al,
2006).
H11: In diabetes… they believed that diabetes
could be cured that is one…. second belief, if I take
my insulin or medication I can eat anything …
14
PHARMACISTS’ PERSPECTIVES
3)Common Counselling Approaches
• Standard treatment approaches - minimise confusion
among the patients during consultation.
• Avoid too much information that they have to digest.
• Interdisciplinary teams can positively impact glycaemic
control in patients.
H12:
In pharmacy, we agree to have a common ground.
These are the things that we have to tell them. We make
sure we tell the people the same things. But sometimes
it’s quite difficult because a lot of the information doesn’t
get across….
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PHARMACISTS’ PERSPECTIVES
4) Communication
– Communication tools have a major influence on the
depth of patient involvement in decision-making
– Approach in giving information (verbal, tabular,
graphical versions) helped patients become involved in
the decision-making.
– Thus, pharmacists viewed that their approaches to
patient education differed from other HCPs.
• H10: ours…. the approach… it is different from them…even
the leaflets we do it ourselves because we know what the
patients need…we look into their needs…we think they should
know this... and this…
– Diabetic education and patient counselling involved all
aspects of the disease and can be time consuming.
– Counselling by pharmacists depended on how
receptive the patients were towards the information
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and the education level.
PHARMACISTS’ PERSPECTIVES
5)
Knowledge about medications
Pharmacist, (H11), believed that some patients lacked
education about medicines especially patients
I think it is lack
from the kampong or rural areas.
of education when… you
know… kampong people
like… with lack of
education… maybe we
have a bit of problem
there… 'cos they don’t…
after you educate them,
talk to them, they still do
not see… what we are
talking about.
I find that many times
compliance… much noncompliance due to lack of
education. And if you
actually sit with them, a
lot of them say thank you
“I never know “.
H11
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PHARMACISTS’ PERSPECTIVES
•
•
Sometimes problems occurred when medical officers
initiated new drugs to patients without prior
counselling.
A pharmacist, (H10), counselled the patients to make
sure they really understood the medication prescribed
to them.
Ok… I make sure they really
understand. That’s the ultimate
aim… (By asking questions) ”how
do you take?” It’s very simple. Just
ask them how do you take it. If they
can’t answer…they don’t
understand or they don’t take.
H10:
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PHARMACISTS’ PERSPECTIVES
6) Perceive seriousness of the disease.
• Most patients lacked knowledge of
complexities of treatment, and side
effects of medications.
19
PHARMACISTS’ PERSPECTIVES
• H11, who believed some patients lacked the
knowledge of diabetes and its complications.
Of course, It may
be…sometimes they don’t
know why the family - person
got kidney failure…until you
explain…diabetes can cause
kidney failure. Suddenly they
said…’Yeah…my mum died of
kidney failure and she got
diabetes.’ Then only they
realised…
Some of them know…like
some of them know about
macro vascular…. they don’t
know…they know that if they
have diabetes they can go
blind, get their leg
amputated…this kind. Heart,
cardio part… they don’t
really connect it.
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H011:
PHARMACISTS’ PERSPECTIVES
• H09 believed that the
awareness of diabetes
among patients was of
an ‘acceptable level’.
• And thought that ‘a lot
of patients understand,
comply, and try to
meet diet, exercise,
and medication.’
Of course, there’s room for
improvement in all aspects… I
think. You wish you got a bit
more than this… but big
percentage of patients are more
aware of diabetes.
H09:
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RECOMMENDATIONS
• Patients reported better ability to practice
diabetes care when they understood their
disease better.
• The complexity of diabetes requires patients to
be aware of their disease and they must be
educated on the need to control their blood
glucose levels.
INTRODUCTION
OBJECTIVES
METHODOLOGY
METHOD
DATA COLLECTION
ANALYSIS
FINDINGS
RECOMMENDATION
CONCLUSION
REFERENCES
• HCPs must be partners to patients so that they
are aware of the treatment requirement
prescribed by the HCPs.
• Factors that contributed to the control of
diabetes once identified would be used in
management of diabetes.
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CONCLUSION
INTRODUCTION
OBJECTIVES
METHODOLOGY
METHOD
DATA COLLECTION
ANALYSIS
FINDINGS
RECOMMENDATION
CONCLUSION
REFERENCES
Pharmacists believed that:
• patients lacked the knowledge of
diabetes and its complications.
• patients needed to be counselled based
on their ability to understand the
information as some patients have the
ability to meet treatment requirement.
• agreed that information should be
individualised and cited time as a
constraint during consultations;
• The patients’ initiatives to learn more
about diabetes would enhance their
management of their disease.
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CONCLUSION
CONCLUSION
Patients were willing to discuss their problems
about self-managing diabetes.
Pharmacists need to understand their patients’
beliefs about their medicine taking to promote more
awareness and compliance to treatment and
improve control of diabetes.
INTRODUCTION
OBJECTIVES
METHODOLOGY
METHOD
DATA COLLECTION
ANALYSIS
FINDINGS
RECOMMENDATION
More positive approaches are needed in selfmanagement of diabetes and pharmacists’ role in
the health care teams for better outcomes in
diabetes management.
Pharmacists needed to be more visible in their role
as part of the diabetes care team and other chronic
diseases.
CONCLUSION
REFERENCES
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REFERENCES
CONCLUSION
1.
Cockram, CS. (2000) Diabetes mellitus: Perspective from the Asia-Pacific region. Diabetes
Research and Clinical Practice, 50(Suppl. 2):S3-S7.
2.
International Diabetes Federation report. (2003). Diabetes Atlas, Second Edition at
http://www.idf.org accessed October 25, 2005.
3.
Ma, S, Jeffery, CJ, Chee, ET, Suok, KC and Shyong Tai, E. (2003). Associations of
Diabetes Mellitus and Ethnicity with Mortality in a Multiethnic Asian Population: Data from
the 1992 Singapore National Health Survey. American Journal of Epidemiology, 58(6):543552.
4.
Chuang, LM., Tsai, SI, Huang, BY and Tai, TY. (On behalf of the Diabcare-Asia 1998 Study
Group). (2002). The status or diabetes control in Asia—a cross-sectional survey of 24317
patients with diabetes mellitus in 1998. Diabetes UK. Diabetic Medicine, 19:978-985.
5.
Lawton, J, Parry O, Peel, E and Douglas, M. (2005a). Diabetes service provision: a
qualitative study of newly diagnosed Type 2 diabetes patients’ preferences and views.
Diabetic Medicine, 22:1246–1251.
6.
New Straits Times Press. Malaysia Ranks as World No. 1 (But No Thanks). June 17, 2005
pg:6.
7.
Agarwal, G, Pierce, M, and Ridout, D. (2002). The GP perspective: problems experienced
in providing diabetes care in UK general practice. (On behalf of Primary Care Diabetes:
The Primary Care Section of the British Diabetic Association). Diabetic Medicine, 19
(Suppl. 4):13–20.Agarwal et al, (2002)
8.
Conrad, P. (1990). Qualitative research on chronic illness: commentary on method and
conceptual development. Social Science and Medicine, 30(No. II):1257-1263.
9.
Parry, O, Peel, E, Douglas, M and Lawton, J. (2006). Issues of cause and control in patient
accounts of Type 2 diabetes. Health Education Research, 21:97-107.
INTRODUCTION
OBJECTIVES
METHODOLOGY
METHOD
DATA COLLECTION
ANALYSIS
FINDINGS
RECOMMENDATION
CONCLUSION
REFERENCES
25
ACKNOWLEDGEMENT
1. UNIVERSITY OF NOTTINGHAM, UK
2. UNIVERSITY TECHNOLOGY MARA,
MALAYSIA
3. UNIVERSITY KEBANGSAAN MALAYSIA
4. GOVERNMENT OF MALAYSIA FOR
FUNDING
26
THANK YOU
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