Abstract
Type 2 diabetes is rapidly becoming a significant challenge in Uganda and other low and middle-income countries. A large proportion of the population remains undiagnosed. To understand diagnostic delay, we explored the diagnostic pathways for diabetes among patients receiving care at a semi-urban district hospital in eastern Uganda. Eligible participants were patients aged 35-70 years receiving care at the diabetes clinic of Iganga district hospital between April and May 2019 and their healthcare providers. Patients were interviewed using an interview guide to collect information on patients' symptoms and their diagnostic experience. A separate interview guide was used to understand the organisation of the diabetes services and the diabetes diagnostic process at the hospital. Using maximum variation purposive sampling, we selected 17 diabetes patients aged 35-68 years, diagnosed within the previous three years, and the three health workers managing the diabetes clinic at Iganga hospital. The data was analysed using ATLAS.ti version 8 to code, organise and track the data segments. We conducted template analysis using a priori themes derived from the intervals of Walter's model of Pathways to Treatment to identify the factors influencing diagnostic delay. We identified four typologies: a short diagnostic pathway, protracted appraisal pathway, protracted appraisal and diagnostic interval pathway, and delayed treatment pathway. The pathways of patients with protracted appraisal or diagnostic intervals demonstrated strong socio-cultural influences. There was a firm reliance on traditional healers both before and after diagnosis which deferred enrolment into care. Other health system barriers implicated in delayed diagnosis included stock-out of diagnostic supplies, misdiagnosis, and missed diagnosis. Denial of diagnosis was also found to lead to delayed initiation of care. Reducing diagnostic delay requires addressing both negative socio-cultural influences and the adoption of system-wide interventions to address barriers to timely diagnosis.
Highlights
Type 2 diabetes mellitus is estimated to affect 47 million people by 2045, up from 19 million people in 2019
We identified four typologies: a short diagnostic pathway, protracted appraisal pathway, protracted appraisal and diagnostic interval pathway, and delayed treatment pathway
Undiagnosed diabetes is associated with an increased risk of cardiovascular risk factors such as hyperlipidemia, hypertension, and obesity; micro- and macrovascular complications [3, 4]; and up to a three-fold increase in mortality compared to normoglycemic individuals [5]
Summary
Type 2 diabetes mellitus is estimated to affect 47 million people by 2045, up from 19 million people in 2019. Africa is projected to bear the brunt of this increment as 142.9% more people with diabetes are expected compared to 51.2% more people globally [1]. About 3 in 5 adults in sub-Saharan Africa do not know their diabetes status [2]. Underdiagnosis of diabetes in sub-Saharan Africa has been attributed to limited screening, poor access to diagnostic facilities, and a poorly trained health workforce [7]. In Uganda, about half of all individuals with diabetes and 9 in 10 of those with impaired fasting glucose are unaware of their status [10]. The pathways to diabetes diagnosis has not been well elaborated in Uganda, which undermines efforts to improve diagnostic processes.
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