Abstract
BACKGROUND: Patient-centred care (PCC) is associated with better experiences for chronic care encounters and better outcomes. However, its assessment and resultant management outcomes have not been well documented in Malawi. As Malawi strives to institutionalise PCC in its quality-of-care initiatives, documenting its correlates and outcomes is a good starting point in the implementation and advocacy of PCC among chronic care patients, particularly those living with diabetes mellitus (DM). AIM: We sought to assess the level of diabetic patients' perception of PCC and its relationship to self-efficacy, adherence and glycaemic control among patients with DM. STUDY SETTING: This study was done in DM clinics of two district and two central hospitals in southern Malawi. RESEARCH DESIGN AND METHODS: This was a cross-sectional analytical study. We studied 607 subsequent consenting adult patients with DM. We assessed the level of perception of using a locally generated and validated tool and its correlation with self-efficacy, adherence and long-term glycaemic control after a medical encounter. We used K-means clustering, linear and logistic regression, and path analysis in the analysis. OUTCOMES: The study's outcome measures included adherence, self-efficacy, long-term glycaemic control. Adherence included aspects related to medication, diet, lifestyle and appointment keeping and was assessed using the Hill-Bone tool. Self-efficacy was assessed using a Stanford self-efficacy tool while long-term glycaemic control was determined through haemoglobin A1c (HbA1c) point-of-care testing. RESULTS: Overall, the mean score for PCC was 62.86 (SD 14.78). The study highlighted two groups of patients with statistically distinct mean scores of 51.6 (7.8) vs 77.1 (7.2) out of a possible 92 (p<0.001), respectively. More patients (n=234 out of 436), 55.7% belonged to the cluster with an average score of 51.56, highlighting that more patients perceived less PCC and that low perception was more prominent in the patient individualisation and involvement subscale. Path analysis showed that female sex and the presence of complications had lower PCC scores than males and those without complications. We found a non-significant relationship between PCC and self-efficacy. Having tertiary education was associated with a 6.4 increase in efficacy scores (β=6.36; 95% CI 1.96 to 10.76, p<0.05). Both PCC and self-efficacy were positive predictors of adherence independently. Having perceived better PCC was associated with a marginal 0.03-point increase in one's adherence scores (β=0.03; 95% CI 0.01 to 0.04, p<0.001). The effect of efficacy on adherence was of similar magnitude. Self-efficacy and adherence were both positive predictors of blood sugar control independently. Better self-efficacy was associated with a 0.03 unit decrease in the level of HbA1c (β=-0.03; 95% CI -0.04 to -0.022, p<0.001). Additionally, as adherence scores went higher, there was a 0.15 unit decrease in HbA1c (β=-0.15; 95% CI -0.25 to -0.02, p<0.05) signalling better glycaemic control. CONCLUSIONS: Although this study did not find a direct correlation between PCC and glycaemic control, it has demonstrated that PCC medical encounters could potentially improve glycaemic control by enhancing patients' adherence to their diabetes management plans. Even though PCC is not an end in itself, medical encounters that prioritise good relational ambience, patient involvement and capacitation are promising interventions in DM care, especially for patients with or at risk of DM complications. The general lack of patient individualisation and involvement elements found in the medical encounters in our study could explain why PCC hardly has an impact on self-efficacy. The study highlights the importance of PCC in DM patient management and outlines important innovative adaptations towards transforming medical education to equip and appraise interpersonal skills that have an impact on patient-reported experiences and outcomes.