Intervening in the local health system to improve diabetes care: lessons from a health service experiment in a poor urban neighborhood in India
Intervening in the local health system to improve diabetes care: lessons from a health service experiment in a poor urban neighborhood in India
复制标题
干预当地卫生系统以改善糖尿病护理：印度贫困城市社区卫生服务实验的经验教训
作者：
U. Bhojani;P. Kolsteren;B. Criel;S. de Henauw;Thriveni S. Beerenahally;R. Verstraeten;N. Devadasan
背景：已知有许多有效的卫生服务干预措施来改善糖尿病护理。然而，几乎没有证据表明，在现实世界资源有限的情况下，这种干预措施是否有效。目的评价采用RE-AIM(REACH，Efficient/Efficient，采用，Implementation，and Maintenance)框架改善糖尿病护理的干预措施。设计一项准实验研究在印度南部的一个贫穷的城市社区进行。4个卫生机构提供干预(n=163名糖尿病患者)，4个匹配的机构作为对照(n=154)。干预措施包括向糖尿病患者提供适当的文化教育，使用仿制药，以及糖尿病管理的标准治疗指南。在6个月干预期之前和之后对患者进行调查。我们在干预设施进行了实地观察和对医生的采访。通过差异性分析，使用定量数据评估干预的范围及其对患者的知识、实践、医疗费用和血糖控制的有效性。对定性数据进行了主题分析，以了解干预措施的采用、实施和维护。结果覆盖范围：在访问干预设施的人中，52.3%的人接触到教育部分，只有7.2%的人开了仿制药。医生们很少使用糖尿病治疗的标准治疗指南。有效性：干预对患者的知识、医疗费用或血糖控制没有统计学和临床上的显著影响，他们的实践得分略有下降。采用：所有设施都采用了教育部分，而除一所设施外，所有设施都采用了仿制药处方。执行情况：干预措施的执行情况不佳，特别是在使用仿制药和标准治疗指南方面。医生对仿制药的疗效、质量、可获得性和患者可接受性的担忧解释了仿制药处方的局限性。患者认为疾病应该通过药物治疗的观念限制了医生在糖尿病早期使用非医疗管理。限制使用标准治疗指南的另一个原因是，这些医生主要为先前由专家提供特定治疗计划的患者提供后续护理。维护：干预设施在干预期间后继续使用海报和电视监视器进行健康教育。用于糖尿病管理的仿制药和标准治疗指南的使用仍然非常有限。结论在资源有限的现实环境中实施有效的卫生服务干预是具有挑战性的，而且可能不能有效地改善患者的预后。干预措施需要考虑患者和医疗保健提供者的经验和看法，以及宏观层面的政策如何转化为当地卫生系统的实践。
Background Many efficacious health service interventions to improve diabetes care are known. However, there is little evidence on whether such interventions are effective while delivered in real-world resource-constrained settings. Objective To evaluate an intervention aimed at improving diabetes care using the RE-AIM (reach, efficacy/effectiveness, adoption, implementation, and maintenance) framework. Design A quasi-experimental study was conducted in a poor urban neighborhood in South India. Four health facilities delivered the intervention (n=163 diabetes patients) and the four matched facilities served as control (n=154). The intervention included provision of culturally appropriate education to diabetes patients, use of generic medications, and standard treatment guidelines for diabetes management. Patients were surveyed before and after the 6-month intervention period. We did field observations and interviews with the doctors at the intervention facilities. Quantitative data were used to assess the reach of the intervention and its effectiveness on patients’ knowledge, practice, healthcare expenditure, and glycemic control through a difference-in-differences analysis. Qualitative data were analyzed thematically to understand adoption, implementation, and maintenance of the intervention. Results Reach: Of those who visited intervention facilities, 52.3% were exposed to the education component and only 7.2% were prescribed generic medications. The doctors rarely used the standard treatment guidelines for diabetes management. Effectiveness: The intervention did not have a statistically and clinically significant impact on the knowledge, healthcare expenditure, or glycemic control of the patients, with marginal reduction in their practice score. Adoption: All the facilities adopted the education component, while all but one facility adopted the prescription of generic medications. Implementation: There was poor implementation of the intervention, particularly with regard to the use of generic medications and the standard treatment guidelines. Doctors’ concerns about the efficacy, quality, availability, and acceptability by patients of generic medications explained limited prescriptions of generic medications. The patients’ perception that ailments should be treated through medications limited the use of non-medical management by the doctors in early stages of diabetes. The other reason for the limited use of the standard treatment guidelines was that these doctors mainly provided follow-up care to patients who were previously put on a given treatment plan by specialists. Maintenance: The intervention facilities continued using posters and television monitors for health education after the intervention period. The use of generic medications and standard treatment guidelines for diabetes management remained very limited. Conclusions Implementing efficacious health service intervention in a real-world resource-constrained setting is challenging and may not prove effective in improving patient outcomes. Interventions need to consider patients’ and healthcare providers’ experiences and perceptions and how macro-level policies translate into practice within local health systems.
影响因子：
12.7
作者：
Glasgow, RE;Vogt, TM;Boles, SM
通讯作者：
Boles, SM