Perception of Educators about Quality of Diabetes Education Services at Primary Health Care Level in Khartoum State, Sudan

This work was carried out in collaboration between all authors. Author SAB designed the study, wrote the protocol, and wrote the first draft of the manuscript. Authors AAB and SAB revised the thematic analysis. Authors MAA and KMAS revised the final themes and the literature searches. Authors HAAM and MAA revised the discussion. All authors read, revised the manuscript for consistency and approved the final manuscript. ABSTRACT Introduction: Promoting positive life style is a strategy for Results: All educators were females. Their ages were between 25-55 years. The majority were holders of a university degree with different basic disciplines. The working duration ranged between 3 to 25 years. Ten of them were working in governmental health centers and 12 in nongovernmental ones. Few educators were trained on diabetes education (structural quality care). Most of them agreed on the lack of diabetes education materials and specific education program (structural quality care). The majority agreed on the absence of team work and their role is to weight the patients. Most of educators educate individuals rather than groups (process quality care). The majority was not satisfied with education services at the health centers and most of educators reflected the poor knowledge and negative behaviour of the diabetic patients (outcome quality care). Conclusions: Diabetes education services at primary health care are insufficient. Most of educators were not certified educators. Education services lack team work and strategic plans. Diabetic patients have poor knowledge and behaviour regarding diabetes management.


INTRODUCTION
Diabetes mellitus is becoming the most common epidemic among non-communicable diseases in low-and middle-income countries [1]. Patients with diabetes and non-diabetic population, both need the full information and education to control diabetic status as well as prevent the occurrence of the disease respectively. Promoting positive life style is a composite strategy for delaying and reducing the incidence of diabetes and its complications as well [1].
Educators can contribute to change the patients` lifestyle through provision of scheduled education sessions [2]. Education of diabetic patients had a significant effect on metabolic control measures of diabetic status that makes the patients value the services [2]. Patients that value and adhere to health information could affect the perception of all care providers at health care system including educators [3]. The frequent in-service training of care providers on diabetes had an effect on the effectiveness of education of patients` attitudes and behaviors [4].
To the best of our knowledge, qualitative studies regarding quality of diabetes education were almost absent particularly at primary care level in the Sudan.
The aim of this study is to determine the perception of educators about the quality of education services provided to diabetic patients at the health centers in Khartoum State.

Study Design
This is a qualitative study carried out among educators working at primary care level in Khartoum State.

Study Area
The study area was the health centers of two types, the ones that established and managed by the government and the others that established and managed by international and national organizations (Non-governmental health centers). Both provide primary care services and supervised by Khartoum State Ministry of Health.

Study Population
The study population was employed educators in both types of the health centers regardless of any inclusion criteria.

Sample Size
The sample size was determined on saturation of data provided during focus group discussion. The method of sampling selection was carried as follows:

Data Collection Method
The discussion was moderated by a qualified social researcher using guiding open ended questions and supervised by the first author. A trained note taker registered all the data yielded How education sessions are conducted, duration and the content? What are the methods of education and schedules? What are the education materials you are using for the education session? How you follow up the diabetic patient after education? Let us know about your satisfaction with education services provided in the health centers. Describe some outcomes and constraints of diabetes education that happened during your work as educator and constraints.
in the groups' discussion. Timely cross checking was made by the first author. The duration of MFGD sessions lasted between 60-90 minutes. After completion of data collection, the educators were involved in a diabetes education workshop run by DNCDs.
The guiding questions included general information and several questions were about education services for diabetic patients [ Table 1 above].

Data Analysis
Content of the notes taken from the educators` discussion was prepared into themes by two independent researchers. Themes were organized according to the dimensions of quality of care, structure, process and outcome [5] that were endorsed by all authors.

Characteristics of Educators
All educators were females, their age ranged between 25-55 years. The majorities were holders of a university degree and graduated from different disciplines mainly: Faculties of Art, Animal Production, Accountancy, Commercial, Business and Management, Finance and Mathematics. Some were holders of secondary school Sudanese certificate and few of them were nurses with bachelor degree in nursing sciences [ Table 2]. The working duration ranged from 3 to 25 years. Few of them were employed for less than three years prior to the study. Ten were working in governmental health centers and 12 in nongovernmental ones.
Almost all educators at the health centers in Khartoum State were not certified educators. They were having qualifications from different basic backgrounds that far away from education and counseling domains of health issues. This is an area of weakness in diabetes education services at primary care level; where qualifications and higher education levels have an effect on the knowledge and the efficiency of provision of diabetes education [6,7]. Most of diabetes education services in other countries are run by nurses [8,9]. Nurses are more appropriate and relevant to health issues and have the potentials for providing diabetes education even if they are not trained specifically for education of diabetic patients.

Structure quality care
The majority of educators presented negative perception about the availability of resources for diabetes education. Most of them not trained on diabetes education. Some agreed on the absence of specific education units for education. Some said there are no specific plans or strategies for education services [ Table 3].
In this study, some audio-visual tools were installed in some health centers, but none of them were used for diabetes messages. This is an area of system weakness where frequent monitoring and maintenance of equipment ensure the continuous flow of services. Using audio-visual tools for education had a significant effect on the patients` knowledge regarding diabetes [10]. The types of educational tools and methods have a great effect on the support of self-management among diabetic patients [11]. Some educators mentioned lack of special unit for education. This is an area of privacy concern for individual education. Individual education was shown in few studies to have a positive effect of self-management and the knowledge of the patients [12]. In this study most of the educators were not trained on diabetes. Specific training on diabetes could improve the knowledge and skills of the educators to perform proper counseling and promote diabetes self-management education of the patients [13].

Process quality care
The majority of educators agreed on the absence of team work and the absence of diet plan for diabetes. Almost all agreed on the absence of standard models of education, lack of follow up system for diabetic patients and absence of registration of patients' information. Few educators used to replicate the material handed to them during their training and used it for educating the patients. Most of them agreed on the need for standards and relevant materials for diabetes education. Very few educators conducted education sessions for diabetic children.    In this study the education services were provided on individual bases. It had shown that patients value the education services provided by a group of providers and adhere to information given [14]. Changing the knowledge of the diabetic patients towards positive attitude needs multidisciplinary team which was absent in this study [15]. Another two trained educators added: "The materials we have from the training courses were not enough to be used for the large number of diabetic patients in the health center……………Although we were trained on diabetes education; but doctors do not refer diabetic patients and they refer children with malnutrition for education." In this study educators could use their potentials to provide the education services to diabetic patients. Care provider had shown willingness to learn more and change their performance in counseling for better services [16].

Outcome quality care
Most of the educators were not satisfied with the diabetes services provided at the health centers. The majority of educators mentioned that they were not satisfied for one or more of the following reasons: In this study the educators reflected some behaviour of diabetic patients regarding diabetes management. Behavioural change of diabetic patients needs time to step forward towards positive health. Poor knowledge of diabetic patients on diabetes management makes them under the spell of local habits which delays their access to health system care until the occurrence of complications [17]. In this study; frequent absence of doctors and insufficient laboratory investigations make the educators dissatisfied. Instability of trained health care providers disturbs the flow of services that leads to dissatisfaction of other providers [18]. In general; patients need qualified care providers and quality organization structure to help in diabetes management. It is worth mentioning that non-diabetic persons were seeking diabetes education and counseling in well-equipped and staffed centers [19]. The practical diabetes education guidelines and frequent training are needed with emphasis on quality curriculum, skills of problem solving, communication and decision making [20]. Poor provider-patient communication and inadequate organizational structure are major causes of dissatisfaction of educators. This is reflected on the lack of adherence of patients to self-care measures [21]. Our study is supported by evidence obtained from a qualitative study conducted among nurses 'educators [22]. They lacked the adequate knowledge about counseling of diet and physical activities and communication skills [22]. The poor coordination with health providers and insufficient educational material are the main obstacles as reflected by nurses [22].

CONCLUSION AND RECOMMENDA-TION
Diabetes education services at primary health care are insufficient and need strong organization structures. Most of educators were not certified as health educators. The majority of educators agreed on the absence of team work, standard mode of education, follow up system and standard guidelines. Most of educators reflected the poor knowledge and behaviour of diabetic patients regarding diabetes management. Diabetes education services need to be considered by the Khartoum State Ministry of Health.

ETHICAL CLEARANCE
Ethical clearance was obtained from ethical committees in the Ministry of Health in Khartoum State and Faculty of Medicine in University of Khartoum. Written detailed informed consent was signed by each educator prior to discussion. The informed consent included benefits, risks and the data confidentiality.