Qualitative results from an evaluation of a hospital-based type 2 diabetes self-management and education program in rural Ghana

The burden of type 2 diabetes will most likely triple in low-income countries by 2025; however, there seems to be little evaluation of management and education programs in an effort to prepare the public health workforce. This project summarizes qualitative results from an evaluation of a hospital-based type 2 diabetes management and education program in rural Ghana. 113 diabetic clients and 3 hospital staff members completed semi-structured interviews regarding their experiences with diabetes and the hospital's program, barriers and facilitators to diabetes management, and knowledge and perceptions of management techniques. Approximately 50 members of the local diabetic's association participated in a town hall meeting about the same topics. All exchanges were held in English when possible, audio-taped, and transcribed. Three main themes emerged: 1) the program's recommended management techniques did not reflect the context of management in rural Ghana. For example, the town had no public fitness facilities, and in general it is considered immodest to exercise publicly, particularly for women, yet the hospital continued to recommend exercise as a management technique. 2) Diabetics expected the hospital to use an ecological framework to deliver diabetes services while hospital staff felt their responsibility was limited to education and pharmaceutical provision. Among other suggestions, clients thought that the hospital could provide transportation to and from monthly physicals and education sessions, lobby the government for an expanded health insurance formulary, and provide absent-from-work slips to facilitate program attendance. 3) Program clients were engaged and often discussed economic, political, or cultural determinants of their diabetic health. Many identified the introduction of the National Health Insurance Scheme as a pivotal point in their diabetes management because it made their drugs free. Many also noted the cycle of poverty and illness. These themes illustrate that: 1) in resource-poor settings, where individual behavioral capacity is constrained by external factors, the traditional programmatic focus on individual management behaviors could lead to a misappropriation of already limited resources and 2) diabetes programs in resource poor settings could benefit from a participatory structure. Enthusiastic, thoughtful clients can help programs prioritize and focus available resources on significant barriers or facilitators to diabetes management and enable process evaluation.