Barriers and Facilitators to Primary Care Management of Type 2 Diabetes in China: A Mixed Methods Study

Abstract

Abstract Background: Diabetes mellitus has surged to become a global health emergency. The prevalence of type 2 diabetes (T2DM) in China is over 10%, affecting around 114 million people. Despite the inclusion of T2DM in the National Basic Public Health Service Program (NBPHSP), most people with T2DM experience challenges in achieving optimal management targets. This study aimed to identify barriers and facilitators of diabetes management from the perspectives of primary health care (PHC) service providers and recipients. Methods: This mixed-methods study was conducted in Shijiazhuang City, Hebei Province, China. A quantitative PHC facility survey was conducted in all administrative districts and qualitative in-depth interviews were conducted in one district with government officials, medical staff, patients with T2DM, and their family members. Interviews were thematically analyzed, and findings were synthesized using Michie’s COM-B theory. Results: A total of 197 village/community level PHC facilities and 66 township/street level PHC facilities answered the survey, and 42 in-depth interviews were conducted. The primary facilitators stemmed from the NBPHSP policy, which standardized the basic infrastructure, medical equipment (99% equipped with blood pressure measuring devices and glucometers), and medication for the PHC facilities, provided training on NCD prevention and control (95% received training workshops), and compensated the healthcare workers based on the quantity of public health service they provided. However, we found that PHC providers have become ensnared in a detrimental cycle characterized by inadequate capacity, overwhelming workloads, insufficient income, limited career development opportunities, and challenges in attracting young talents. Although all covered by the national medical insurance schemes, patients experienced capability constraints primarily driven by low education levels, advanced age, low health literacy, and a proliferation of misinformation. These factors influenced patients’ motivation to be actively engaged in care and contributed to inertia to intensify treatment and achieve their clinical management goals. Conclusion: This study identifies several major barriers from the perspectives of both PHC providers and patients with T2DM. Our findings suggest there are substantial opportunities to strengthen the NBPHSP, including improving the capacity and the income level of the PHC providers, attracting and retaining skilled health workers in rural areas, supporting patients to improve their health literacy and take a more active role in their health care, and improving access to high-quality care through digital health approaches. Trial registration: ClinicalTrials.gov (record NCT02726100, 03/22/2016).