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Phase II: Health Systems Strengthening

How can we make the healthcare offered to people with diabetes better and more robust? This is the question we seek to answer in this second phase of the research project. In doing so, we will take particular account of the existence of inequalities in access to health care and in the management of type 2 diabetes.


In this phase we will study and evaluate (i.e. assess) how care for people with type 2 diabetes is provided. We will do this in the areas where we are carrying out the project, District D17D06 of Quito, Ecuador’s populous capital, and the less densely populated Eloy Alfaro District of Esmeraldas, a coastal region. We want to find out how health services can be strengthened and how improvements can be effective and also feasible.


To achieve our goal, this phase will identify the facilitators and barriers to successful management of type 2 diabetes. We call “facilitators” those social or personal circumstances that favour behaviours, in this case diabetes care and management, while “barriers” are those that hinder, make it difficult or impossible. Proximity to a health centre would be an example of a facilitator, while the impossibility of doing physical exercise due to lack of time or a safe place to do it would be an example of a barrier.  The identification of these barriers and facilitators should include not only the perspective of people with diabetes, but also that of their families, caregivers and health professionals, among other stakeholders.

How things are done is what in science is called methodology and in essence distinguishes scientific knowledge from other types of knowledge.  In this phase we will use a systematic review, a cohort study, qualitative interviews and focus groups.

Systematic review is the orderly and explicit evaluation of the literature, i.e. everything published, to ascertain the state of knowledge. In our review we wanted to identify the facilitators and barriers to successful management of type 2 diabetes in Latin America and the Caribbean. Once the review was conducted, we found that successful management of the disease depends to a large extent on factors that are beyond the control of the patients.

You can see the different factors identified here. For more information see the full article.

Factors influencing diabetes management

A cohort study is basically a research method that involves a group of people with common characteristics over a specific period of time. We collect information about the health care received and their health status from health records. We also interview patients to learn about their socio-demographic characteristics, social support and perceived quality of life. We will use a scientific questionnaire (DHP-18), which allows us to estimate the impact that diabetes has on each person’s life, and which has been previously validated for use in Ecuador. For more information, please consult publication on this linguistic and psychometric validation.

Our cohort study will involve 1,152 diabetic patients, 576 for each district in which we conduct the project. With this study we want to measure in percentage terms the number of people who are able to comply with the recommendations given to them, i.e. whether they visit their family doctor or ophthalmologist, control their blood glucose, follow up their medication, etc. With these data we will have the possibility to identify the inequality factors that produce the differences between different patients.

The qualitative interview or in-depth interview is a data collection technique that focuses more on opinions, points of view and impressions than on numerical data, through a conversation between the interviewee and the research team.

As part of the CEAD research work, 19 interviews were conducted among people with diabetes and/or hypertension in Ecuador and Spain, to learn about their perceptions of their health experience and the management of their disease prior to the COVID-19 pandemic, during confinement and after the current reorganisation of health care, and to reflect on the importance of health determinants in the management of chronic diseases.

In order to disseminate the results of the semi-structured interviews, a series of videos have been created showing some of the outcomes and themes most present in the lives of people with diabetes and/or hypertension and how they have changed in the aftermath of the COVID-19 pandemic. The gender perspective, their socio-economic conditions, their immigrant status, modify the impacts of COVID-19 on the people interviewed.

Watch the videos on our Youtube channel

Results Qualitative Study

A focus group is a research technique in which through interaction between researchers and participants their opinions and experiences about the object of study are collected.

Once the information has been obtained through the above techniques, it will be discussed in the focus groups in order to analyse what are the weaknesses and strengths of the health care system for the management of type 2 diabetes in primary care centres and in the community. For example, we will discuss the impossibility of reconciling personal, family and work life, which causes difficulty in accessing health services due to the incompatibility of working hours or being in charge of the care of a dependent person, among others.