Diabetes and related complications comprise 8.9% of mortality in Armenia, with a greater burden in the rural regions. The Children of Armenia Fund (COAF) has been actively involved with various health projects in rural Armenia for over fifteen years. One of their goals is to improve primary care through training physicians in community clinics. However, little is understood about what individual, community, and structural factors lead to successful diabetes management. This exploratory, qualitative research project seeks to understand the behaviors, attitudes, and practices of type 2 diabetes management among patients as well as local healthcare providers (nurses, family medicine physicians, and endocrinologists).
We employed purposive sampling to recruit research participants and conducted qualitative interviews with health professionals (n=17) and patients with diabetes (n=25) in eight COAF-affiliated rural clinics (Arteni, Aragatsavan, Dalarik, Hatsik, Horom, Karakert, Myasnikyan, and Panik). We administered a demographic questionnaire to participants with type 2 diabetes and used semi-structured interview guides to explore themes such as diagnosis, knowledge and management of diabetes and related complications. We also discussed the facilitators and challenges of successful diabetes management. Interview transcripts were coded and analyzed using grounded theory.
Diagnosis of type 2 diabetes is made according to symptoms, incidentally and through the World Bank supported screening program. Glucometers and urine tests are commonly used for diagnosis as well as management; HbA1c is infrequently used due to the high cost of the test and its limited availability in certain clinics. Additionally, patients were knowledgeable about the symptoms and complications of diabetes but many cited stress and fear as causes of the condition. Many received diet counseling but few reported exercise/physical activity counseling. A nutrient-rich diet is easier to maintain during the warmer seasons due to the increased accessibility and availability of fruits and vegetables. Participants reported successful medication adherence as well as common usage of various herbal, home remedies. COAF-supported seminars on diabetes education increased patients’ awareness of diabetes management and recommended lifestyle changes. Both health professionals and patients expressed concerns about the quality and variability of the free diabetes medications provided by the government, citing that foreign ones have less side effects and greater efficacy.
Facilitators of successful management include: free medications (oral tablets and insulin), ease of access to local clinics, and patient education. Barriers to successful management include: scarce availability and accessibility of foods rich in complex carbohydrates (particularly wheat), reported poor quality of state-funded medications, financial barriers to purchasing glucometer strips and accessing regional clinics for specialist referrals, and low self-reported physical activity. Health professionals shared varying impressions of gender differences and risk factors in diabetes management, which should further be explored.