Exploring the Type 2 Diabetes Management in the Primary Care Setting in Ratchaburi Province , Thailand

This study was a cross-sectional study on 1,890 patients with type 2 diabetes who were participating in the primary care research networks in the Ratchaburi Province of Thailand. Data was obtained through a self-administered questionnaire about the state of health and care. Patient medical records were used to examine the condition of complications, treatment and several indicators of DM care. The data was processed by using logistic regression to analyse the effect of independent variables on the dependent variable. The hypothesis-null was rejected at p-values <0.05.


INTRODUCTION
Diabetes Mellitus (DM) is a disease of chronic metabolic disorders characterized by hyperglycemia.This situation occurs because the body does not produce enough insulin hormones needed by the body to metabolize.Insulin hormone deficiency then results in high blood sugar levels.Diabetes can be divided into 2 types, namely type 1 or Type 2 relative diabetes [1 -3].The development of DM in Thailand is very common, one of the causes is due to lifestyle changes that lead been operating under the policy of developing primary care and primary care clinics.The plan to establish a family clinic in the year 2017-2026 included a total of 28 Cluster and 76 teams covering the population of 764,136 people in order to provide an accessible quality healthcare services.In the year 2017, 6 clusters and 16 teams were established, accounting for 21.05% of the total team.In addition, it has been reported that there are 11.06% of DM cases related to the diagnosis of several other diseases [7].Comorbid diseases both acute and chronic are often experienced by patients with type 2 diabetes mellitus; this condition often makes doctors to deal with the main symptoms that appear first.This situation is increasingly complicated because not all patients get holistic care from various angles of health science, especially because the primary care system cannot provide a multi-discipline service [8].
The purpose of this study was to describe the results of type 2 DM management in primary health care from Sub-District Health Promoting Hospital (SDHPH).In particular, the specific objective of this study was to observe the practice of DM care, the complexity of the problems experienced by type 2 DM sufferers and health and non-health personnel involved in the team, control of cardiovascular related risk factors and the spectrum of interventions dealt by doctors treating them.

Research Location
The data was collected from Sub-District Health Promoting Hospital in Ratchaburi Thailand from January 2018 to March 2018.The participants were diabetic patients aged over 18 years old selected by multistage cluster random sampling.Ratchaburi is one of the western provinces of Thailand.The province is divided into 10 districts including Mueang Ratchaburi, Chom Bueng, Suan Phueng, Damnoen Saduak, Pak Tho, Ban Pong, Bang Phae, Photharam, Wat Phleng and Ban Kha.The first stage was performed to select 5 districts out of 10 districts [9].They were Danein district Meuang district, Baang pair district, Potharam district and Wat Phleng district.At the second stage, among the total of 84 Subdistrict Health Promoting Hospitals (SDHPH), 42 Sub-district Health Promoting Hospitals (SDHPH) were selected [10].Subdistrict Health Promoting Hospital has a vital role in providing integrated health services for people, families and even individuals.The hospital is usually led by a director, medical personnel, nurses, public health experts, technicians and health analysts, dental health technicians, as well as traditional medicine technicians.In Thailand, one Health Promoting Hospital serves around 5,000 residents [11].In the last stage, we selected patients with preset qualifications.The data of 1,890 patients of age over 15 years were collected, and 85 percent of them were successfully interviewed.

Ethical Considerations
The Institutional Research Board of Boromarajonani College of Nursing, Ratchaburi (IRB-BCNR) -Ministry of Public Health approved this study with the certificate of approval number BCNR.No. 01/2018.

Procedures
In this study, the term clinician in primary services includes general practitioners/family doctors, dentists, internist doctors, nurses, and Public health scholar, Thai traditional medicine and physical therapist.The criteria for patients included in this study were (1) type 2 DM declared by a doctor; (2) at least 18 years of age; (3) had visited primary care clinician at least once in the last 2 years; (4) speak and read Thai.

Measures
In the early stages, doctors complement self-administered questionnaires.The contents include patients' characteristics (including age, gender, and length of practice), diabetes-related complications and comorbidities, levels of glycosylated hemoglobin and cardiovascular drugs consumed by patients.In the next stage, if the doctor permits to participate in this study, the patient would complete the self-administered questionnaire.This questionnaire contained demographic data and data related to DM services and treatments received.When the patient conducts an inspection visit at the next health service, the doctor or the study coordinator would fill out the form related to the patient's DM condition from the patient's medical record, also including the examination of hemoglobin glycolysis (HbA1c).

Control Targets
The main indicator in controlling diabetes is HbA1c.If the value <7%, thisindicates controlled DM; 7.0% to 7.9% means it is moderately controlled and if >8%, it means it is uncontrolled.These categories are based on the standards of medical care in diabetes from the American Diabetes Association (ADA) [8] to classify action levels for HbA1c.For this study, the dependent variable was divided into categories; if the value <7% it indicates controlled DM coded as 1 while if the value >=7% it indicates poor controlled DM coded as 0.

Data Analysis
Analyses were performed with STATA Versions 5.0.The descriptive statistics were implemented to describe the variables by presenting the mean and standard deviation.To determine whether diabetes outcomes (HbA1c levels) were associated with patient characteristics, diabetes-related complications, practice design strategies, and diabetes and cardiovascular medications were assessed by using logistic regression analysis.Furthermore, logistic regression was applied to analyze the effect of the independent variables toward the dependent variable.The statistical significant was considered to reject hypothesis-null at < 0.05.

RESULTS
Table 1 presents the characteristics of 1,890 respondents.The mean age of respondents was 57.56 years (+12.10)and male respondents were more than women.Most respondents (36.20%) had a complete Bachelor's degree.The majority of the respondents were (28.35%) employees.Regarding the duration of diabetes, the majority (28.35%) had 11-20 year old disease.In terms of body mass index, 29.67% had body mass index between 25.0-29.9(overweight).Regarding complications and comorbidities, the major complication and comorbidity included nephropathy (33.63%) while Ischemic heart disease was the major of other comorbid health problems (48.3%).Furthermore, patients were mostly taking Antihypertensive (67.80%) and ACE Inhibitor or ARB (59.00%).The HbA1c level (42.74%) of majority was lower than 7.0%

Factors Associated with HbA1c Level
Table 2 shows the logistic analysis which showed that education and treatment significantly influenced Hemoglobin A1c level at significant levels of 0.05.On the other hand, the age, occupation, and duration of diabetes did not affect Hemoglobin A1c level.Regarding education, patients who had Bachelor's degree (adjusted odds ratio 0.815, 95% CI 0.671-1.535.p=0.044) were less likely 0.815 times to had glycemic control compared to those who were not educated.Furthermore, those who had post graduate education were less likely 0.568 times (adjusted odds ratio 0.568, 95% CI 0.559-1.922.p=0.008) to had glycaemic control compared to those who were not educated.Regarding treatment, patients treated by oral diabetes medications and Insulin (adjusted odds ratio 0.887, 95% CI 1.226-2.906.p=0.004) were less likely 0.887 times to had glycaemic control compared to those who were not taking any medication and were on diet.

DISCUSSION
This study shows that the average age tendency of respondents is 57.56 years [12 -14].In this study, male respondents dominated.Furthermore, during the study period, it was found that only about 42.74% of respondents' blood sugar was controlled optimally.This is lower when compared to the results of other studies that show the number 54.6% in the primary care setting as well.In Europe, patients who get treatment in primary are 42% -57% who have well-controlled glycemic levels.But on the contrary, in Asia, this figure only reached 21% of patients who had HbA1c below 7%, with a mean HbA1c of 8.6% [15].According to study results in Asian countries, including Thailand, more than half of the patients did not have access to HbA1c.As in this study, only 83.9% of patients measured HbA1c which reached 100% in European countries [16 -17].
This study found that the educational factor was one of the factors associated with patient glycemic control.This result is in line with a systematic study which states that the level of education and the role of nurses are associated to the level of patients' recovery [18 -20].

HUMAN AND ANIMAL RIGHTS
No animals/humans were used for studies that are the basis of this research.

CONSENT FOR PUBLICATION
Informed consent was obtained from all the participants involved in the study.

Table 2 . The Logistic Analysis of Factors Associated with HbA1c level (n= 1,890).
The Institutional Research Board of Boromarajonani College of Nursing, Ratchaburi (IRB-BCNR) -Ministry of Public Health approved this study with the certificate of approval number BCNR.No. 01/2018.