Noura A. Abouammoh

1.3.2 Burden of type 2 diabetes

The mortality risk in people with diabetes is doubled compared to their non-diabetic peers (WHO, 2011). Complications of diabetes include: retinopathy, which can lead to blindness in people of working age (Melville et al., 2000); nephropathy “kidney disease”, which is found 17 times more in diabetics, compared to non-diabetic people (Amos et al., 1997); coronary heart disease, which is two to four times higher; stroke, which has a two fold increase among diabetics compared to non-diabetics (Beul, 1994, Morrish et al., 2001); peripheral vascular disease, which causes more than half of non-traumatic lower limb amputations as a complication of diabetes (ADA, 2003); and neuropathy “nerve damage”, which affects up to 50% of people with diabetes (WHO, 2011).

Furthermore, T2DM causes a heavy direct economic burden on health services and indirect burden by limiting the productivity of patients of working age (Hex et al., 2012).

1.3.3 Type 2 diabetes management

Achieving quality of life (QoL) and life expectancy similar to that of the general population is the main goal of managing T2DM (DiabetesUK, 2005). This can be achieved by controlling blood glucose levels to prevent the development of diabetes related complications. Control, in this context, indicates preventing blood glucose levels from getting too high (hyperglycaemia) or too low (hypoglycaemia). Average glycaemia control is assessed by haemoglobin A1c (HbA1c) which gives average glycaemia over a period of two to three months (NICE, 2009). The recommended target HbA1c, according to the National Institute for Health and Care Excellence (NICE), is between 6.5%-7.5% (NHS, 2009).

NICE recommends management of T2DM based on planned steps that start with non-pharmacological management including changing lifestyle behaviours by improving dietary habits and getting physically active (NICE, 2009). If T2DM patients fail to control their blood glucose levels by lifestyle modification, there is a shift to the second step, which comprises adding oral hypoglycaemic agents to the treatment plan. If the second step shows limited control over patients’ blood glucose level, insulin can be added to the plan (NICE, 2009).

As T2DM entails behavioural and lifestyle modifications, it is widely understood that diabetes self-management is crucial (Heisler et al., 2002). However, there is evidence to suggest that technical knowledge of the physician, combined with personal preferences of the patient, should work together to produce an effective management plan (Olivarius et al., 2001, Anderson et al., 1995, Von Korff et al., 1997).

1.3.4 Caring for patients with diabetes

Diabetes is one of the chronic conditions that require significant lifestyle changes in order to be managed successfully. Patients are expected to incorporate diabetes and its management plan into their lives in order to achieve good diabetes control.

The role of health care providers in continuously educating and promoting self-management, improving patients’ QoL and making a treatment plan based on mutual understanding and shared decision-making, is very important when managing diabetes (Heisler et al., 2002, Aikens et al., 2005, Gadsby, 2003). Setting an effective management plan for T2DM patients based on shared decision-making requires good physician-patient communication. For the above reasons, patient-physician communication is particularly important in T2DM as it requires the patient not only to understand, but also to be properly educated and motivated by their physicians to follow the advice they provide.

Health care studies are giving increasing attention to patient-physician communication (Heisler et al., 2002, Stewart, 2001). Effective delivery of health care can be limited by difficulties in communication between patients and health care teams, in general, and physicians, in particular. Patients with chronic conditions, such as diabetes, are long-term clients who have recurrent needs. Their condition requires them to understand its risk factors, be involved in their treatment plan, and recognize their own role in managing it. Evidence suggests that part of the reason why many diabetes patients are not following an optimum management regime can be attributed to the patient-physician relationship (Heisler et al., 2002). Furthermore, The World Health Organisation (WHO) has long supported the right of both patients and their physicians to participate in health care delivery (WHO, 1987). Applying this requires good communication between patients and their physicians.

1.3.5 Prevalence of diabetes in Saudi Arabia

Diabetes in SA is reaching epidemic proportions. The prevalence of diabetes in this country is one of the highest in the world (IDF, 2009). In 2004, an extensive national survey revealed that almost 24% of the Saudi population between the ages of 30 and 70 suffer from diabetes (Al-Nozha et al., 2004) and the prevalence of this condition is increasing. At the same time, the prevalence of poor control of the condition is also increasing (Al-Baghli et al., 2010, Azab, 2001, Abu-Zeid and Al-Kassab, 1992), prevalence of diabetes complications are rising, and multiple complications are frequent (Alwakeel et al., 2008). As a result of the previously mentioned lifestyle characteristics among Saudis, coupled with culture-based constraints, including social etiquette, people’s negative views on females and older people exercising, and the extremely hot weather that restricts outdoor activities, this high prevalence of T2DM is to be expected.

1.4 An overview of the health care system in Saudi Arabia

The Saudi government is currently giving a high priority to health care services. Special attention is being given to primary health care services, as one of the MOH’s key aims is to decrease the load on hospitals and focus on promoting health and preventing diseases. At present, the MOH is the main provider of health care services in the country, and their main source of finance. Under the MOH there are 259 hospitals with 35,828 beds and 2,259 primary health care centres (PHCCs), which are distributed over the country. The Riyadh region has the largest number of PHCCs (MOH, 2012). Furthermore, the private sector, which also provides all levels of health care and health programmes, is supervised by the MOH, which in addition manages, plans and formulates health policies (Al-Yousuf et al., 2002).

PHCCs are the network through which primary health care services are delivered in SA. They are equivalent to general practices in the UK. The numbers of PHCCs are dramatically increasing as a result of the increasing demands of the population (MOH, 2012). Most of these PHCCs are located in the main cities such as Riyadh, Jeddah and Dammam. Each PHCC provides health care services to a defined population within its catchment area (Al-Yousuf et al., 2002).

The total expenditure allocated for the health sector has been increased over recent years by the Saudi government. It increased from 5.6% of the total national budget in 2008 to 6.2% in 2009 and more than 6.5% in 2012 (MOH, 2012). Full and free access to all healthcare services is provided to citizens and expatriates working within the public sector (Aldossary et al., 2008).

Other autonomous agencies provide and finance health care services for national citizens, such as university hospitals, which are operated by the Ministry of Higher Education, or for employees and their families, such as military hospitals, which are operated by the Ministry of Defense and Aviation (Al-Yousuf et al., 2002). The military hospitals in SA are reputed to have high standards and are operated by staff who hold qualifications from developed countries such as the UK, the US and Australia.

The referral system in SA is theoretically similar to that of the National Health Service (NHS) in the UK. Under the Saudi health system, patients first present their symptoms to the General Practitioners (GPs) who are assigned to the community-based PHCCs found around the country (MOH, 2012). Referrals to secondary health care, or to general hospitals, take place if complications are suspected by the GP. Family physicians assigned to hospital-based primary health care clinics will then assess patients and refer them to a specialist if their condition requires that, or send them back to the community-based PHCCs. If the hospital-based specialist controls a patient’s condition, they will be sent back to their community-based GP for follow-up. However, tertiary care will be sought if a patient’s condition requires higher specialized care, such as an organ transplant (Almalki et al., 2011).

The high level of attention and generous expenditure on the part of the government, along with the plans of the MOH to improve its health care system, have made the Saudi system comparable to some of the best-known health care systems in the world. Among the WHO Member States, the Saudi health care system ranked 26 according to WHO criteria, which was based on how far health systems are achieving their goals and how efficiently they are using their resources in doing so (WHO, 2000).

However, it has been noted that the rapid acquisition of national wealth has led to more emphasis on the number of hospitals and PHCCs and the importance of using technology for medical interventions. This has required the country to recruit physicians from abroad as the huge demand for the health care service cannot be met by local physicians (Searle and Gallagher, 1983).

Although the Saudi health care system is comparable to those in the developed world, the system is not without its challenges. The Saudi health system is challenged by a shortage of national health care providers (Searle and Gallagher, 1983, AL-Ahmadi and Martin, 2005, MOH, 2012). Health care services are therefore mainly provided to the population through IMGs.