Understanding healthcare pathways of patients with diabetes: insights from an exploratory study in a government sub-district hospital of Bangladesh

Abstract

Introduction: The prevalence of diabetes mellitus in Bangladesh was 13.75% in 2018. The healthcare system of Bangladesh makes it challenging to deliver integrated non-communicable disease service. There is a lack of resources at the primary healthcare level, a difficult pluralistic healthcare system to navigate, and limited evidence on diabetic care pathways in the context of Bangladesh. As diabetes mellitus is a leading cause of morbidity and mortality, understanding these pathways is vital for developing an equitable healthcare system tailored to chronic disease management. Methods: This facility-based qualitative exploratory study was conducted at the Upazila Health Complex in Keraniganj, Dhaka, Bangladesh. By applying convenient sampling, a total of 22 in-depth interviews were conducted with respondents visiting the NCD corner of the UHC, from November 22, 2024 to December 11, 2024. Descriptive statistics about the respondents were evaluated using STATA V17. Thematic analysis of the interviews were done. Results: The majority of the respondents were aged 40-69 years (81.8%) and female (68.2%), married (86.4%), Muslim (91%) and living in peri-urban areas (91%). 45.5% of the respondents had no formal education, 72,7% were unemployed and most household incomes were generally less than 15,000 BDT. 59% of respondents have lived with diabetes for 2-5 years and 77.3% had other comorbidities too. Respondents navigated complex care pathways, involving both formal and informal healthcare providers, with the longest pathway having five points of care. Most participants delayed seeking care due to attributing symptoms to other diseases, minimal perceived severity, or beliefs about diabetes, with many managing symptoms through home remedies. Delays were longest among women. Triggers that prompted seeking care were worsening symptoms, advice from social networks, or referrals from providers. The common initial points of care were private providers and drug-sellers, with UHCs generally becoming the final care provider by the third point of care. UHCs were preferred for their affordability, accessibility, and ability to manage comorbidities. Most respondents rated UHC services as good, yet unavailable essential medicine or diagnostic tests, short consultation times, disrespectful behavior, and insufficient privacy impacted patient experiences. Elderly and women with children struggled with access to distant hospitals. Private care was expensive and often led to discontinuation, while informal providers were chosen for affordability. One respondent took service from parallel providers. Expenses, especially for those with comorbidities, caused financial strain, often forcing difficult decisions between managing diabetes and other health conditions. Conclusion: Respondents with diabetes navigated complex care pathways and encountered various categories of healthcare providers. While PHC facilities serve as critical hubs, there is a need to address challenges such as inconsistent medicine supply, unavailability of diagnostic facilities, inadequate consultation practices, and the financial burden of respondents to create equitable, patient-centered care for diabetes chronic diseases in resource-limited settings.