# 'Operating in the dark’: perspectives of health service users and healthcare workers on quality of diabetes care at a public referral hospital in Blantyre, Malawi - a qualitative study

## TL;DR

This study explores the quality of diabetes care at a public hospital in Malawi from the perspectives of patients and healthcare workers.

## Contribution

The study provides qualitative insights into the challenges and strengths of diabetes care in a Malawian public hospital setting.

## Key findings

- Participants appreciated free services like glucose checks and medications at the clinic.
- Understaffing led to long waiting times and inadequate patient assessments.
- Many patients had uncontrolled blood sugar levels and organ damage due to poor care.

## Abstract

Poor glycemic control and medical complications are common among people living with diabetes in Malawi. The healthcare system is part of an environment in which people with diabetes manage themselves and can act as facilitators or barriers to diabetes self-management. This study aimed to explore the effects of diabetes health service users and healthcare workers (HCW) on the quality of diabetes care at the Queen Elizabeth Central Hospital (QECH) diabetes clinic.

This qualitative study recruited service users (people with diabetes and family members) and HCW (medical doctors, clinical officers, and nurses) at the QECH diabetes clinic, a public referral hospital in Blantyre. Data saturation was achieved after 20 individual in-depth interviews (IDI) and four focus group discussions with people with diabetes, 20 IDIs with family members of people with diabetes, and eight key informant interviews with HCW. A framework analysis approach was used to guide data analysis.

Participants shared positive and negative perspectives regarding the quality of care. Five major themes emerged: healthcare system organization, drug and treatment equipment supply, pathways to diagnosis, diabetes health education and awareness, and ongoing monitoring, prevention, and management of complications. The participants appreciated free services at the clinic, including glucose checks, health education, and medications. However, many were concerned with understaffing, which led to long clinic waiting times, inadequate patient assessments, and failure to diagnose diabetes complications.

The quality of care in diabetes clinics is perceived to be mixed. Although service users appreciated the available services, they noted other deficits at the clinic, which made it difficult for them to receive necessary care. Good quality diabetes care services are essential for improving the well-being of people with diabetes.

Approximately 468,000 people live with diabetes (sugar disease) in Malawi. Diabetes mellitus is a condition in which an individual has an abnormally high blood sugar level. People with sugar diseases can control their blood sugar levels to near normal levels by eating recommended healthy foods, exercising regularly, and taking medications appropriately if applicable. When people with diabetes fail to achieve adequate control of their sugar levels, they experience damage to important organs such as the brain, kidney, heart, eyes, and nerves. Good quality care for people with diabetes at health facilities also helps keep the disease under control.

This study was conducted at the Queen Elizabeth Central Hospital (QECH) diabetes clinic, a non-paying referral hospital in Blantyre. Nearly seven out of every ten people attending the QECH diabetes clinic had uncontrolled sugar levels, and five out of every ten had one or more organs damaged due to the high sugar content. The aim of our study was to determine the perceptions of the quality of diabetes care at QECH among people with diabetes, their family members, and healthcare workers.

We interviewed 20 people with diabetes, 20 family members; two medical doctors, two clinical officers and four nurses at the facility. We also conducted four group interviews with people with diabetes (each group having 6-12 people). Participants perceived that care services at the diabetes clinic were good in some areas and not good in others. Many participants were concerned with understanding at the clinic, which led to long clinic waiting times, incomplete patient assessments, and failure to identify diabetes complications. These findings provide an overview of the situation at the QECH diabetes clinic and how it affects care. There is a need to address the identified problems to improve care at facilities to help promote the well-being of people with diabetes.