Diabetes management in Guinea Bissau: a situational analysis

Introduction There is an increasing commitment in the African Region towards diabetes care, following acknowledgement that it is an important public health issue which needs to be addressed in order to improve population health. We conducted a situational analysis of diabetes care in Guinea Bissau in order to identify the main issues faced in the management of the disease in this country. Methods The study design was qualitative and data collection was done using semi directive interviews and focus groups with participants involved in primary diabetes care and management in Guinea Bissau (health care professionals, non-governmental organization staff, traditional healers) and patients. The data was analyzed using the five-phase approach of the thematic analysis framework. Results The major themes identified included: the lack of specialists and properly trained healthcare personnel; no standardized care protocol for diagnosis, treatment, follow up and proper management for diabetic patients; resources poor primary health care settings; no validated epidemiological dataset on prevalence and the lack of awareness about diabetes (in general population and also in medical staff). Conclusion This first situational analysis can serve as a baseline to develop an action plan to address the main issues identified.


Introduction
A fast change in the demographic status, the socio-cultural lifestyle as well as financial transitions have become the drivers for rising numbers of diabetes mellitus (DM) cases within the sub-Saharan African region [1,2]. As a result, increasingly diabetes and associated complications are the underlying cause of premature deaths and disability [3,4]. That is the case of Guinea Bissau, a country characterized by a resource poor health system [5]. There is an increasing commitment in the country towards diabetes care, following acknowledgement that it is an important public health issue which needs to be addressed in order to improve population health.
Optimal diabetes management requires an organized, systematic approach and the involvement of a coordinated team of dedicated health care professionals working in an environment where patientcentered high-quality care is a priority [6,7]. In order to improve patient care, it is important to conduct an accurate needs assessment and identification of the priority areas that must be improved [8,9]. Therefore, we decided to conduct a situational analysis of diabetes care in Guinea Bissau with the aim of determining what factors need to be addressed before planning and designing an effective intervention. This research study was developed based on the work experience of the researchers who wish to design an evidence-based intervention which will be viable in the particular, resource and manpower poor setting of health care in Guinea Bissau.

Methods
Participant selection and sampling: prior to the start of the interviews with the relevant health care professionals (HCP), the

General Secretary of the Ministry of Foreign Affairs and International
Cooperation and the General Director of Health Institutions from the Ministry of Health were involved in the initial discussion of the goals of the study and which sites were to be selected in order to get the best picture of the situation of diabetes care in the country. We decided to interview HCP involved in DM care from different levels of the healthcare system: one referral hospital in the capital, the Hospital Nacional Simão Mendes (HNSM) and two rural health care centers, namely the Cacheu and Pelundo primary healthcare centers. We also sought to interview traditional healers since in Guinea Bissau, particularly in rural areas, the general population use their services.
We wanted to evaluate whether traditional healers have the needed awareness and skills to provide adequate treatment and management for diabetic patients who opt to use their services. Only one traditional healer accepted to be interviewed. Furthermore, the staff from several NGOs involved in diabetes care were also included in our investigation which were previously identified by the research team and further informed by the interviews with the HCP. The following NGOs were selected for the study: "Ayuda, Intercambio y Desarrollo" (AIDA), "Ceu e Terra"(CT), the "Associação nacional de defesa dos pacientes diabeticos" (ANDPD) and "Associação de luta contra a diabetes em Guinée Bissau" (ASLUCO Diabetes GB). In order to identify the entire spectrum of challenges encountered in the management of this disease we also interviewed the diabetic patients themselves and let them put forth their difficulties and views on possible solutions. These patients were recruited through ASLUCO Diabetes-GB, a local diabetic patient run NGO. Twenty patients responded to our call. Participants of all ages came with type 1 diabetes (3 children with their mother) and type 2 diabetes (17 adults). We used a heterogeneous purposive sampling approach [10] when recruiting the participants during the visits of the different selected sites. The inclusion criteria for the participants included all those involved in the care of DM affected patients and willing to participate in the study. The characteristics of the different participants are presented in Table 1.  Table 1. The patients were asked to introduce themselves in a few words (name, type of diabetes and treatments with the circumstance of discovery). Once the presentations were done, we encouraged them to express themselves using the photolanguage technique [11]: patients chose pictures cut out of newspapers beforehand. The instruction was to choose an image that speaks to them in connection with their disease. Then we let the patients express themselves freely through the chosen picture which allowed us to reflect on their experience, their knowledge of the disease and difficulties.
Throughout the interviews and patient focus group, the interviewers made efforts to clarify information without influencing or contributing with any views (so as to avoid bias and confounding in the data collection process). The interviewers made immediate written notes of the data after the interviews and focus group in order to ensure that none of the details were omitted. All three interviewers compared their notes, a means to validate the collected data. As part of the ethical aspects of the study, oral consent was obtained from all those who agreed to participate in the study and the workshops.
Data analysis: the documented data was analyzed by applying thematic analysis involving a comparative strategy to the interview results as well as use of an iterative process for identifying similarities as well as variations in each of the transcripts [12]. In phase 1, the data was read again and again as an iterative process so as to become familiar with it, notes were made and sections of potential interest to the research objectives were highlighted [13]. In phase 2, using the constructs and framework of the constructive grounded theory,

Diabetes is becoming an increasing problem in Guinea
Bissau [15,16].The data collected indicates that diabetes treatment, management and follow up are quite poor in spite of the fact that non-communicable diseases have been attended to within the Health Strategic Plan of Guinea Bissau [17]. The most important challenge identified was the severe lack of resources in this poor country.
Hospitals, especially in primary care facilities, lack basic diagnostic tools such as glucose meters, testing strips, and laboratory capacity to measure glycosylated hemoglobin (HbA1C). This is consistent with several studies in African countries [18][19][20]. In addition, health care expenditure is mostly out-of-pocket. Patients, including children and

Conclusion
Our findings suggest that any intervention that is designed in the future has to take the identified themes into account and find suitable solutions that can work in Guinea Bissau. In addition, further research is needed to find prevalence data which is at present not very comprehensive due to lack of epidemiological studies. The Guinea Bissau health care system requires funds, training for specialized medical staff and educational campaigns directed towards diabetes awareness. This will help in improving the present situation of poor diabetes management in the country.
What is known about this topic  Diabetes care requires a patient centered multi-disciplinary team approach;  There is a lack of reliable evidence about the true magnitude of the burden of disease and its complications in LMICs, and what interventions will or will not be effective in this context;  As diabetes prevalence increases in LMICs, there is a need for more evidence to guide health systems organisation and planning.

What this study adds
 This is the first analysis of diabetes care in Guinea Bissau;  The health system in Guinea Bissau is struggling to provide basic care responding to diabetic patients needs and expectations;  Our results can serve as a baseline to develop an action plan to address the main issues identified. Table 1: characteristics of the participants interviewed