PERSPECTIVES OF PHARMACISTS IN THEIR ROLE IN TYPE 2 DIABETES MANAGEMENT: A QUALITATIVE STUDY

1. PERSPECTIVES OF PHARMACISTS IN THEIR ROLE IN TYPE 2 DIABETES MANAGEMENT: A QUALITATIVE STUDY M. A. Salmiah1, C. Anderson2, Nor Azmi K.3 1 University Technology MARA, Shah Alam, MALAYSIA 2 University of Nottingham, Nottingham, UNITED KINGDOM 3 National University of Malaysia, Kuala Lumpur, MALAYSIA

2. INTRODUCTION • Countries all over the world are concerned with the high prevalence of diabetes. • 150 million people worldwide (6% of world population) • WHO estimated the number will increase to 350 million by year 20251 (Cockram, 2000a). • Expenditure worldwide is estimated to be US$ 213 billion and US$ 396 billion by year 2025 2 (International Diabetes Federation report, 2003). • 75% of these estimates are expected to be from developing countries 3, 4 (Ma et al, 2003 and Chuang et al, 2002). • With this scenario, diabetes will burden the health care system, with other chronic diseases such as coronary heart disease, asthma, hypertension, and kidney failure 5(Lawton, et al, 2005a). INTRODUCTION OBJECTIVES METHODOLOGY METHOD DATA COLLECTION ANALYSIS FINDINGS RECOMMENDATION CONCLUSION REFERENCES

3. INTRODUCTION (cont.,) • Adequate blood glucose control is vitalin diabetes management to prevent complications. Yet, despite the various interventions, diabetes control remains a global problem to health care professionals (HCPs). • Diabetes poses a major threat to this phenomenon as more people suffer from diabetes due to the increase in the level of obesity worldwide; • uncontrolled diabetes has led to an increase in complications • has doubled the cost of treating these patients. • Complications of diabetes have caused Malaysia to be ranked as number one in kidney failure due to diabetes6. INTRODUCTION OBJECTIVES METHODOLOGY METHOD DATA COLLECTION ANALYSIS FINDINGS RECOMMENDATION CONCLUSION REFERENCES

4. INTRODUCTION (cont.,) • With the growing number of people diagnosed with diabetes, there is a need to understand why the lack of control among diabetes in Malaysia. • Agarwal et al, (2002)7 - stressed that giving out new medical information was found to be minimally effective in changing practice behaviours regarding diabetes but education which addresses attitudes and knowledge is more effective in improving diabetic outcomes. • Qualitative research on chronic illness.8 INTRODUCTION OBJECTIVES METHODOLOGY METHOD DATA COLLECTION ANALYSIS FINDINGS RECOMMENDATION CONCLUSION REFERENCES

5. OBJECTIVES • Understand qualitative research method. • Explore patients’ use of medicines and adherence in managing chronic illness in Malay patients with Type 2 diabetes. • Perspectives and experiences of pharmacists in managing chronic illness of Type 2 diabetes. INTRODUCTION OBJECTIVES METHODOLOGY METHOD DATA COLLECTION ANALYSIS FINDINGS RECOMMENDATION CONCLUSION REFERENCES

6. METHODOLOGY Qualitative research: • allows understanding of patients’ experiences, their knowledge and coping strategies. • ensures understanding of the problems that quantitative research is unable to uncover and to enhance a more complete scenario in the research field. • methods are used in health research to understand each patient as an individual who requires a consulting strategy that is appropriate to his or her unique needs. INTRODUCTION OBJECTIVES METHODOLOGY METHOD DATA COLLECTION ANALYSIS FINDINGS RECOMMENDATION CONCLUSION REFERENCES

7. METHODOLOGY (cont.,) Why do qualitative research? • “… It should begin to close the gap between the sciences of discovery and implementation.” (Jones 1995). • Qualitative method allows researcher to attend closely to what happened in the empirical world in the study. • E.g. studies of people with chronic illness: • with an interest in how they experienced time, • illness affected them, • self concept, • identity and duration of the study, • problems of disclosing illness how, when, why ill people talked about their conditions. INTRODUCTION OBJECTIVES METHODOLOGY METHOD DATA COLLECTION ANALYSIS FINDINGS RECOMMENDATION CONCLUSION REFERENCES

8. METHOD • In-depth interviews were carried out using a purposeful sampling participants. • Theoretical sampling of grounded theory was used to determined the participants of 18 Malay patients (age range= 15-75 years; male= 9; female= 9) in Endocrinology Clinic in Malaysia. • 13 health care professionals (HCPs) were interviewed. INTRODUCTION OBJECTIVES METHODOLOGY METHOD DATA COLLECTION ANALYSIS FINDINGS RECOMMENDATION CONCLUSION REFERENCES

9. METHOD • Computer Aided Qualitative Data Analysis Software (CAQDAS) NVivo v.2 was used to enhance data management and analysis. • The transcribed interviews were subjected to grounded theory (thematic) analysis. • Using NVivo - transcribed audiotapes were analysed to identify emerging themes, then coded according to categories. • Issues raised during interviews were identified as contributory factors to non-adherence to diabetes treatment. INTRODUCTION OBJECTIVES METHODOLOGY METHOD DATA COLLECTION ANALYSIS FINDINGS RECOMMENDATION CONCLUSION REFERENCES

10. DATA COLLECTION ANDANALYSIS • In-depth interviews using semi-structured interview guides were used to gather data for the project. • These interviews were recorded (with respondents consent) using audiotapes and transcribed for data analysis. • This involved: • Developing codes, categories, and themes on the data • Generating hypothesis or proposal from the data, • Analysing narratives of participants’ experiences with their diabetic patients’ illness and coping with their treatment regimen. INTRODUCTION OBJECTIVES METHODOLOGY METHOD DATA COLLECTION ANALYSIS FINDINGS RECOMMENDATION CONCLUSION REFERENCES

11. FINDINGS • Themes that emerged from interviews with pharmacists found that patients: • faced problems in integrating their treatment regimen to achieve the desired blood glucose level. • lacked knowledge about their medicines, dietary control, medicine taking, complexities of treatment, and side effects of medications. • fail to integrate treatment regimen which could lead to uncontrolled diabetes. INTRODUCTION OBJECTIVES METHODOLOGY METHOD DATA COLLECTION ANALYSIS FINDINGS RECOMMENDATION CONCLUSION REFERENCES

12. PHARMACISTS’ PERSPECTIVES 1)Patientslack dietary control and understanding of sugarless diet. Diet was difficult to control among Malay patients due to demands made by their family members. As H12 explained, INTRODUCTION OBJECTIVES METHODOLOGY METHOD DATA COLLECTION ANALYSIS FINDINGS RECOMMENDATION CONCLUSION REFERENCES

13. PHARMACISTS’ PERSPECTIVES So what is the reason for this? Especially with Malay family? It is a vicious circle…they always have “kenduri”, their families come back… their children come back and they have to cook. SMA H12

14. PHARMACISTS’ PERSPECTIVES 2) Patients attitude towards diabetes • H11 stressed the importance of patients’ ‘education level’ to understand the disease and added that patients believed diabetes could be cured and they also thought that they could eat anything if they took their insulin. • Patients’ mistaken belief that their condition has been cured should also be addressed 9(Parry et al, 2006). H11: In diabetes… they believed that diabetes could be cured that is one…. second belief, if I take my insulin or medication I can eat anything …

15. PHARMACISTS’ PERSPECTIVES • Common CounsellingApproaches • Standard treatment approaches - minimise confusion among the patients during consultation. • Avoid too much information that they have to digest. • Interdisciplinary teams can positively impact glycaemic control in patients. H12: In pharmacy, we agree to have a common ground. These are the things that we have to tell them. We make sure we tell the people the same things. But sometimes it’s quite difficult because a lot of the information doesn’t get across….

16. PHARMACISTS’ PERSPECTIVES 4) Communication • Communication tools have a major influence on the depth of patient involvement in decision-making • Approach in giving information (verbal, tabular, graphical versions) helped patients become involved in the decision-making. • Thus, pharmacists viewed that their approaches to patient education differed from other HCPs. • H10: ours…. the approach… it is different from them…even the leaflets we do it ourselves because we know what the patients need…we look into their needs…we think they should know this... and this… • Diabetic education and patient counselling involved all aspects of the disease and can be time consuming. • Counselling by pharmacists depended on how receptive the patients were towards the information and the education level.

17. PHARMACISTS’ PERSPECTIVES 5)Knowledge about medications Pharmacist, (H11), believed that some patients lacked education about medicines especially patients from the kampong or rural areas. I think it is lack of education when… you know… kampong people like… with lack of education… maybe we have a bit of problem there… 'cos they don’t… after you educate them, talk to them, they still do not see… what we are talking about. I find that many times compliance… much non-compliance due to lack of education. And if you actually sit with them, a lot of them say thank you “I never know “. H11

18. PHARMACISTS’ PERSPECTIVES • Sometimes problems occurred when medical officers initiated new drugs to patients without prior counselling. • A pharmacist, (H10), counselled the patients to make sure they really understood the medication prescribed to them. Ok… I make sure they really understand. That’s the ultimate aim… (By asking questions) ”how do you take?” It’s very simple. Just ask them how do you take it. If they can’t answer…they don’t understand or they don’t take. H10:

19. PHARMACISTS’ PERSPECTIVES 6) Perceive seriousness of the disease. • Most patients lacked knowledge of complexities of treatment, and side effects of medications.

20. H11, who believed some patients lacked the knowledge of diabetes and its complications. PHARMACISTS’ PERSPECTIVES Of course, It may be…sometimes they don’t know why the family - person got kidney failure…until you explain…diabetes can cause kidney failure. Suddenly they said…’Yeah…my mum died of kidney failure and she got diabetes.’ Then only they realised… Some of them know…like some of them know about macro vascular…. they don’t know…they know that if they have diabetes they can go blind, get their leg amputated…this kind. Heart, cardio part… they don’t really connect it. H011:

21. H09 believed that the awareness of diabetes among patients was of an ‘acceptable level’. And thought that ‘a lot of patients understand, comply, and try to meet diet, exercise, and medication.’ PHARMACISTS’ PERSPECTIVES Of course, there’s room for improvement in all aspects… I think. You wish you got a bit more than this… but big percentage of patients are more aware of diabetes. H09:

22. RECOMMENDATIONS • Patients reported better ability to practice diabetes care when they understood their disease better. • The complexity of diabetes requires patients to be aware of their disease and they must be educated on the need to control their blood glucose levels. • HCPs must be partners to patients so that they are aware of the treatment requirement prescribed by the HCPs. • Factors that contributed to the control of diabetes once identified would be used in management of diabetes. INTRODUCTION OBJECTIVES METHODOLOGY METHOD DATA COLLECTION ANALYSIS FINDINGS RECOMMENDATION CONCLUSION REFERENCES

23. CONCLUSION Pharmacists believed that: • patients lacked the knowledge of diabetes and its complications. • patients needed to be counselled based on their ability to understand the information as some patients have the ability to meet treatment requirement. • agreed that information should be individualised and cited time as a constraint during consultations; • The patients’ initiatives to learn more about diabetes would enhance their management of their disease. INTRODUCTION OBJECTIVES METHODOLOGY METHOD DATA COLLECTION ANALYSIS FINDINGS RECOMMENDATION CONCLUSION REFERENCES

24. CONCLUSION CONCLUSION Patients were willing to discuss their problems about self-managing diabetes. Pharmacists need to understand their patients’ beliefs about their medicine taking to promote more awareness and compliance to treatment and improve control of diabetes. More positive approaches are needed in self-management of diabetes and pharmacists’ role in the health care teams for better outcomes in diabetes management. Pharmacists needed to be more visible in their role as part of the diabetes care team and other chronic diseases. INTRODUCTION OBJECTIVES METHODOLOGY METHOD DATA COLLECTION ANALYSIS FINDINGS RECOMMENDATION CONCLUSION REFERENCES

25. REFERENCES CONCLUSION • Cockram, CS. (2000) Diabetes mellitus: Perspective from the Asia-Pacific region. Diabetes Research and Clinical Practice,50(Suppl. 2):S3-S7. • International Diabetes Federation report. (2003). Diabetes Atlas, Second Edition at http://www.idf.org accessed October 25, 2005. • Ma, S, Jeffery, CJ, Chee, ET, Suok, KC and Shyong Tai, E. (2003). Associations of Diabetes Mellitus and Ethnicity with Mortality in a Multiethnic Asian Population: Data from the 1992 Singapore National Health Survey. American Journal of Epidemiology,58(6):543-552. • Chuang, LM., Tsai, SI, Huang, BY and Tai, TY. (On behalf of the Diabcare-Asia 1998 Study Group). (2002). The status or diabetes control in Asia—a cross-sectional survey of 24317 patients with diabetes mellitus in 1998. Diabetes UK. Diabetic Medicine,19:978-985. • Lawton, J, Parry O, Peel, E and Douglas, M. (2005a). Diabetes service provision: a qualitative study of newly diagnosed Type 2 diabetes patients’ preferences and views. Diabetic Medicine,22:1246–1251. • New Straits Times Press. Malaysia Ranks as World No. 1 (But No Thanks). June 17, 2005 pg:6. • Agarwal, G, Pierce, M, and Ridout, D. (2002). The GP perspective: problems experienced in providing diabetes care in UK general practice. (On behalf of Primary Care Diabetes: The Primary Care Section of the British Diabetic Association). Diabetic Medicine, 19 (Suppl. 4):13–20.Agarwal et al, (2002) • Conrad, P. (1990). Qualitative research on chronic illness: commentary on method and conceptual development. Social Science and Medicine, 30(No. II):1257-1263. • Parry, O, Peel, E, Douglas, M and Lawton, J. (2006). Issues of cause and control in patient accounts of Type 2 diabetes. Health Education Research,21:97-107. INTRODUCTION OBJECTIVES METHODOLOGY METHOD DATA COLLECTION ANALYSIS FINDINGS RECOMMENDATION CONCLUSION REFERENCES

26. ACKNOWLEDGEMENT • UNIVERSITY OF NOTTINGHAM, UK • UNIVERSITY TECHNOLOGY MARA, MALAYSIA • UNIVERSITY KEBANGSAAN MALAYSIA • GOVERNMENT OF MALAYSIA FOR FUNDING

27. THANK YOU