BackgroundThe management of patients with diabetes mellitus is complex. Some research has been done in developed countries to attempt to determine the factors that influence quality of care of patients with diabetes: Factors thus far postulated are usually categorised into patient, clinician and organisational factors. Our study sought to discover the main barriers and facilitators to care in the management of diabetes in primary care in a low/middle income country.MethodsA qualitative study, based on reflexive ethnography using participant observation, semi-structured interviews of clinicians (10) and group interviews with paramedical staff (4) and patients (12) in three purposively sampled health centres, along with informal observation and discussions at over 50 other health centres throughout Tunisia. A content analysis of the data was performed.ResultsOver 400 potential barriers or facilitators to care of patients with diabetes in primary care in Tunisia emerged. Overall, the most common cited factor was the availability of medication at the health centre. Other frequently observed organisational factors were the existence of chronic disease clinics and clinicians workload. The most commonly mentioned health professional factor was doctor motivation. Frequently cited patient factors were financial issues, patient education and compliance and attendance issues. There were notable differences in the priority given to the various factors by the researcher, physicians, paramedical staff and the patients.ConclusionWe have discovered a large number of potential barriers and facilitators to care that may potentially be influencing the care of patients with diabetes within primary care in Tunisia, a low/middle income country. An appreciation and understanding of these factors is essential in order to develop culturally appropriate interventions to improve the care of people with diabetes.

OBJECTIVE -To identify the organizational, physician, and patient factors associated with the quality of care of patients with diabetes in a low-/middle-income country.RESEARCH DESIGN AND METHODS -Data from 2,160 randomly selected patients with diabetes were extracted from the manual medical records of a nationwide sample of 48 randomly selected health centers. Physician and organizational characteristics were collected from national reports, questionnaires, interviews, and observation at the centers. Univariate and multivariate regression analyses were undertaken to identify associations with four quality-ofcare scores, based on processes and intermediate outcomes of care and 53 potential explanatory factors.RESULTS -The mean age of the study population was 62.4 years, mean duration of diabetes was 8.4 years, 62% were female, and 94% had type 2 diabetes. In the final multivariate models, factors independently and significantly associated with higher process-of-care scores were regional affluence, doctor motivation, and the use of chronic disease clinics (P Ͻ 0.05). Health centers with younger patients and increased availability of medication were independently and significantly associated with improved outcome-of-care scores (P Ͻ 0.05). The final models of the four quality-of-care scores explained 55-71% of the variations in scores.CONCLUSIONS -Use of chronic disease clinics, availability of medication, and possibly doctor motivation appear to be the most strongly related modifiable factors influencing diabetes care. These findings will be used to develop and implement culturally appropriate quality improvement interventions to improve the quality of diabetes care. We recommend our findings be taken into account in other low-/middle-income countries. Diabetes Care 30:2013-2018, 2007W orldwide, the quality of care of patients with diabetes has been shown to be variable and suboptimal (1-6), despite the evidence that good control of blood pressure and glucose significantly reduces the risk of cardiovascular and microvascular complications (7,8). The management of diabetes is acknowledged to be complex. The quality of diabetes care can be influenced by patient, health professional, and organizational factors (9 -11). Commonly reported patient factors are adherence, attendance, and education together with individual characteristics such as age, sex, and presence of comorbidity (11)(12)(13)(14). Health physician factors include the number, training, and sex of the treating physician and practice team; the role of clinical inertia; and the clinician/ patient relationship (10,12,(15)(16)(17)(18). Many organizational factors have been shown to influence care such as the use of structured diabetes clinics, recall systems, practice guidelines, and educational programs (14,19).Very few studies on the factors influencing the care of patients with diabetes have been reported from low-/middleincome countries, despite the fact that 80% of all chronic disease deaths worldwide now occur in such countries (20). None, to our know...

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