{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,27]],"date-time":"2026-02-27T05:11:13Z","timestamp":1772169073827,"version":"3.50.1"},"reference-count":53,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2025,5,16]],"date-time":"2025-05-16T00:00:00Z","timestamp":1747353600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["wellcomeopenresearch.org"],"crossmark-restriction":false},"short-container-title":["Wellcome Open Res"],"abstract":"<ns3:p>Background Poor glycemic control and medical complications are common among people living with diabetes in Malawi. The healthcare system is part of an environment in which people with diabetes manage themselves and can act as facilitators or barriers to diabetes self-management. This study aimed to explore the effects of diabetes health service users and healthcare workers (HCW) on the quality of diabetes care at the Queen Elizabeth Central Hospital (QECH) diabetes clinic. Methods This qualitative study recruited service users (people with diabetes and family members) and HCW (medical doctors, clinical officers, and nurses) at the QECH diabetes clinic, a public referral hospital in Blantyre. Data saturation was achieved after 20 individual in-depth interviews (IDI) and four focus group discussions with people with diabetes, 20 IDIs with family members of people with diabetes, and eight key informant interviews with HCW. A framework analysis approach was used to guide data analysis. Results Participants shared positive and negative perspectives regarding the quality of care. Five major themes emerged: healthcare system organization, drug and treatment equipment supply, pathways to diagnosis, diabetes health education and awareness, and ongoing monitoring, prevention, and management of complications. The participants appreciated free services at the clinic, including glucose checks, health education, and medications. However, many were concerned with understaffing, which led to long clinic waiting times, inadequate patient assessments, and failure to diagnose diabetes complications. Conclusion The quality of care in diabetes clinics is perceived to be mixed. Although service users appreciated the available services, they noted other deficits at the clinic, which made it difficult for them to receive necessary care. Good quality diabetes care services are essential for improving the well-being of people with diabetes.<\/ns3:p>","DOI":"10.12688\/wellcomeopenres.21374.1","type":"journal-article","created":{"date-parts":[[2025,5,16]],"date-time":"2025-05-16T11:35:07Z","timestamp":1747395307000},"page":"241","update-policy":"https:\/\/doi.org\/10.12688\/wellcomeopenres.crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["'Operating in the dark\u2019: perspectives of health service users and healthcare workers on quality of diabetes care at a public referral hospital in Blantyre, Malawi - a qualitative study"],"prefix":"10.12688","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9337-3583","authenticated-orcid":false,"given":"Chimwemwe","family":"Kwanjo Banda","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Belinda Thandizo","family":"Gombachika","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Moffat","family":"Nyirenda","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4412-9773","authenticated-orcid":false,"given":"Adamson","family":"Muula","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"2560","published-online":{"date-parts":[[2025,5,16]]},"reference":[{"key":"ref-1","article-title":"IDF diabetes Atlas 2021."},{"key":"ref-2","article-title":"Government of the republic of Malawi health sector strategic plan III 2023\u20132030: reforming for universal health coverage.","year":"2022"},{"key":"ref-3","doi-asserted-by":"publisher","first-page":"575-81","DOI":"10.4269\/ajtmh.2010.10-0104","article-title":"A survey of the management, control, and complications of diabetes mellitus in patients attending a diabetes clinic in Blantyre, Malawi, an area of high HIV prevalence.","volume":"83","author":"D Cohen","year":"2010","journal-title":"Am J Trop Med Hyg."},{"key":"ref-4","doi-asserted-by":"publisher","first-page":"3-27","DOI":"10.1177\/089826439100300101","article-title":"Self-management of chronic disease by older adults.","volume":"3","author":"N Clark","year":"1991","journal-title":"J Aging Health."},{"key":"ref-5","doi-asserted-by":"publisher","first-page":"1-7","DOI":"10.1207\/S15324796ABM2601_01","article-title":"Self-management education\u202f: history, definition, outcomes, and mechanisms.","volume":"26","author":"K Lorig","year":"2003","journal-title":"Ann Behav Med."},{"key":"ref-6","article-title":"A review of self-management of diabetes in Africa.","volume":"24","author":"S Iregbu","year":"2016","journal-title":"Afr J Diabetes Med."},{"key":"ref-7","doi-asserted-by":"publisher","first-page":"161","DOI":"10.12688\/aasopenres.12992.2","article-title":"Self-management and its associated factors among people living with diabetes in Blantyre, Malawi: a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations].","volume":"2","author":"C Banda","year":"2019","journal-title":"AAS Open Res."},{"key":"ref-8","article-title":"Package of Essential Noncommunicable disease (PEN) interventions for primary health care in low-resource settings.","year":"2010"},{"key":"ref-9","doi-asserted-by":"publisher","first-page":"127-33","DOI":"10.1007\/s11892-003-0036-7","article-title":"Changing office practice and health care systems to facilitate diabetes self-management.","volume":"3","author":"M Funnell","year":"2003","journal-title":"Curr Diab Rep."},{"key":"ref-10","article-title":"Quality of care.","year":"2025"},{"key":"ref-11","doi-asserted-by":"publisher","first-page":"691-729","DOI":"10.1111\/j.1468-0009.2005.00397.x","article-title":"Evaluating the quality of medical care.","volume":"83","author":"A Donabedian","year":"2005","journal-title":"Milbank Q."},{"key":"ref-12","doi-asserted-by":"publisher","first-page":"40-53","DOI":"10.1177\/0145721716689694","article-title":"Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics.","volume":"43","author":"M Powers","year":"2017","journal-title":"Diabetes Educ."},{"key":"ref-13","doi-asserted-by":"publisher","first-page":"250-64","DOI":"10.2307\/2136745","article-title":"Types and timing of social support.","volume":"27","author":"D Jacobson","year":"1986","journal-title":"J Health Soc Behav."},{"key":"ref-14","first-page":"109-14","article-title":"The quality of care of diabetic patients in rural Malawi: a case of Mangochi district.","volume":"26","author":"A Assayed","year":"2014","journal-title":"Malawi Med J."},{"key":"ref-15","doi-asserted-by":"publisher","first-page":"64S-69S","DOI":"10.1177\/1090198115614313","article-title":"Implementation of policies and strategies for control of noncommunicable diseases in Malawi.","volume":"43","author":"P Lupafya","year":"2016","journal-title":"Health Educ Behav."},{"key":"ref-16","doi-asserted-by":"publisher","first-page":"1-14","DOI":"10.9734\/IJTDH\/2016\/25601","article-title":"Are we treating the right people? Are we treating the people right? Health status, knowledge and quality of life amongst patients with diabetes at a specialized clinic at Kamuzu Central Hospital, Malawi.","volume":"16","author":"A Yassin","year":"2016","journal-title":"Int J Trop Dis Health."},{"key":"ref-17","doi-asserted-by":"publisher","first-page":"109-18","DOI":"10.1016\/j.gheart.2019.05.001","article-title":"Systematic review of hypertension and diabetes burden, risk factors, and interventions for prevention and control in Malawi: the NCD BRITE consortium.","volume":"14","author":"A Amberbir","year":"2019","journal-title":"Glob Heart."},{"key":"ref-18","doi-asserted-by":"publisher","first-page":"214-22","DOI":"10.5014\/ajot.45.3.214","article-title":"Rigor in qualitative research: the assessment of trustworthiness.","volume":"45","author":"L Krefting","year":"1991","journal-title":"Am J Occup Ther."},{"key":"ref-19","article-title":"An introduction to qualitative research","author":"U Flick","year":"2014"},{"key":"ref-20","doi-asserted-by":"publisher","DOI":"10.1177\/16094069221077758","article-title":"Constructivist grounded theory or interpretive phenomenology? Methodological choices within specific study contexts.","volume":"21","author":"M Burns","year":"2022","journal-title":"Int J Qual Methods."},{"key":"ref-21","doi-asserted-by":"publisher","first-page":"349-57","DOI":"10.1093\/intqhc\/mzm042","article-title":"Consolidated Criteria for Reporting Qualitative research (COREQ): a 32-item checklist for interviews and focus groups.","volume":"19","author":"A Tong","year":"2007","journal-title":"Int J Qual Heal Care."},{"key":"ref-22","article-title":"Perspectives of people with diabetes, their family members and Healthcare workers on quality of care - extended data","author":"C Kwanjo Banda"},{"key":"ref-23","doi-asserted-by":"publisher","first-page":"545-7","DOI":"10.1188\/14.ONF.545-547","article-title":"The use of triangulation in qualitative research.","volume":"41","author":"N Carter","year":"2014","journal-title":"Oncol Nurs Forum."},{"key":"ref-24","doi-asserted-by":"publisher","first-page":"522-5","DOI":"10.1093\/fampra\/13.6.522","article-title":"Sampling for qualitative research.","volume":"13","author":"M Marshall","year":"1996","journal-title":"Fam Pract."},{"key":"ref-25","doi-asserted-by":"publisher","DOI":"10.4135\/9781412986151","article-title":"The handbook for focus group research","author":"T Greenbaum","year":"1998"},{"key":"ref-26","first-page":"1123-33","article-title":"Challenges of self-management when living with multiple chronic conditions: systematic review of the qualitative literature.","volume":"60","author":"C Liddy","year":"2014","journal-title":"Can Fam Physician."},{"key":"ref-27","doi-asserted-by":"publisher","first-page":"622-667","DOI":"10.1016\/S2213-8587(17)30181-X","article-title":"Diabetes in sub-Saharan Africa: from clinical care to health policy.","volume":"5","author":"R Atun","year":"2017","journal-title":"Lancet Diabetes Endocrinol."},{"key":"ref-28","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2288-13-117","article-title":"Using the framework method for the analysis of qualitative data in multi-disciplinary health research.","volume":"13","author":"N Gale","year":"2013","journal-title":"BMC Med Res Methodol."},{"key":"ref-29","first-page":"187-208","article-title":"Qualitative data analysis for applied policy research.","author":"J Ritchie","year":"2002","journal-title":"Anal Qual data."},{"key":"ref-30","first-page":"105-17","article-title":"Competing paradigms in qualitative research.","author":"E Guba","year":"1994","journal-title":"Handb Qual Res."},{"key":"ref-31","doi-asserted-by":"publisher","first-page":"63-75","DOI":"10.3233\/EFI-2004-22201","article-title":"Strategies for ensuring trustworthiness in qualitative research projects.","volume":"22","author":"A Shenton","year":"2004","journal-title":"Educ Inf."},{"key":"ref-32","doi-asserted-by":"crossref","first-page":"166-206","DOI":"10.2307\/3348969","article-title":"Evaluating the quality of medical care.","volume":"44","author":"A Donabedian","year":"1966","journal-title":"Milbank Mem Fund Q."},{"key":"ref-33","doi-asserted-by":"publisher","first-page":"2261-72","DOI":"10.2147\/DMSO.S207427","article-title":"Mitigating the burden of diabetes in Sub-Saharan Africa through an integrated diagonal health systems approach.","volume":"12","author":"T Mercer","year":"2019","journal-title":"Diabetes Metab Syndr Obes."},{"key":"ref-34","doi-asserted-by":"publisher","first-page":"955-62","DOI":"10.1377\/hlthaff.2022.00233","article-title":"Modernizing diabetes care quality measures.","volume":"41","author":"D Jiang","year":"2022","journal-title":"Health Aff (Millwood)."},{"key":"ref-35","doi-asserted-by":"publisher","first-page":"1156-64","DOI":"10.1016\/j.eprac.2021.07.001","article-title":"Impact of high deductible health plans on diabetes care quality and outcomes: systematic review.","volume":"27","author":"D Jiang","year":"2021","journal-title":"Endocr Pract."},{"key":"ref-36","doi-asserted-by":"publisher","first-page":"322-6","DOI":"10.4314\/mmj.v29i4.8","article-title":"Use of an electronic medical record to monitor efficacy of diabetes care in out-patients in a central hospital in Malawi: patterns of glycaemic control and lessons learned.","volume":"29","author":"T Allain","year":"2017","journal-title":"Malawi Med J."},{"key":"ref-37","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-023-10039-z","article-title":"Patient\u2019s experiences of diabetes care at a tertiary health facility in Lilongwe, Malawi.","volume":"23","author":"E Nkambule","year":"2023","journal-title":"BMC Health Serv Res."},{"key":"ref-38","doi-asserted-by":"publisher","first-page":"218-23","DOI":"10.4314\/mmj.v29i2.26","article-title":"The challenge of diabetic foot care: review of the literature and experience at Queen Elizabeth Central Hospital in Blantyre, Malawi.","volume":"29","author":"M Kasiya","year":"2017","journal-title":"Malawi Med J."},{"key":"ref-39","doi-asserted-by":"publisher","first-page":"e340-51","DOI":"10.1016\/s2666-7568(21)00089-1","article-title":"The state of diabetes treatment coverage in 55 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data in 680 102 adults.","volume":"2","author":"D Flood","year":"2021","journal-title":"Lancet Healthy Longev."},{"key":"ref-40","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-024-12081-x","article-title":"Barriers and facilitators in the acquisition of diabetes knowledge among tertiary-care nurses in central and southern Malawi: an exploratory-descriptive qualitative study.","volume":"24","author":"M Nyalapa","year":"2024","journal-title":"BMC Health Serv Res."},{"key":"ref-41","doi-asserted-by":"publisher","DOI":"10.1186\/s12875-023-02033-5","article-title":"Perceived readiness for diabetes and cardiovascular care delivery in Mangochi, Malawi: multicentre study from healthcare providers\u2019 perspectives.","volume":"24","author":"P Lutala","year":"2023","journal-title":"BMC Prim Care."},{"key":"ref-42","article-title":"The clinical book","author":"D Sloan","year":"2013"},{"key":"ref-43","article-title":"Malawi standard treatment guidelines","year":"2015"},{"key":"ref-44","doi-asserted-by":"publisher","first-page":"1225-1229","DOI":"10.1111\/dme.14165","article-title":"Back to the future: 25 years of \u2018guidelines for encouraging psychological well-being\u2019 among people affected by diabetes.","volume":"37","author":"J Speight","year":"2020","journal-title":"Diabet Med."},{"key":"ref-45","first-page":"34-7","article-title":"The prevalence of depression among patients and its detection by primary health care workers at Matawale Health Centre (Zomba).","volume":"26","author":"M Udedi","year":"2014","journal-title":"Malawi Med J."},{"key":"ref-46","article-title":"Global report on diabetes","year":"2016"},{"key":"ref-47","doi-asserted-by":"publisher","first-page":"S1-196","DOI":"10.13140\/RG.2.2.29645.90083","article-title":"SEMDSA 2017 guidelines for the management of type 2 diabetes mellitus SEMDSA type 2 diabetes guidelines expert committee.","volume":"21","year":"2019","journal-title":"J Endocrinol Metab Diabetes South Africa."},{"key":"ref-48","doi-asserted-by":"publisher","first-page":"S1-95","DOI":"10.1080\/22201009.2012.10872287","article-title":"The 2012 SEMDSA guideline for the management of type 2 diabetes (Revised).","volume":"17","author":"A Amod","year":"2012","journal-title":"J Endocrinol Metab Diabetes South Africa."},{"key":"ref-49","doi-asserted-by":"publisher","first-page":"S7-S12","DOI":"10.2337\/dc19-S001","article-title":"1. Improving care and promoting health in populations: standards of medical care in diabetes-2019.","volume":"42","year":"2019","journal-title":"Diabetes Care."},{"key":"ref-50","doi-asserted-by":"publisher","DOI":"10.1111\/dme.15065","article-title":"Diabetes distress mediates the relationship between depressive symptoms and glycaemic control among adults with type 2 diabetes: findings from a multi-site diabetes peer support intervention.","volume":"40","author":"Y Qian","year":"2023","journal-title":"Diabet Med."},{"key":"ref-51","article-title":"WMA declaration of Helsinki \u2013 ethical principles for scientific requirements and research protocols 2013"},{"key":"ref-52","article-title":"Constitution of the Republic of Malawi. 4th ed","year":"1999"},{"key":"ref-53","article-title":"Extended data - quality of diabetes care at QECH 2025","author":"C Banda"}],"container-title":["Wellcome Open Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/wellcomeopenresearch.org\/articles\/10-241\/v1\/xml","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/wellcomeopenresearch.org\/articles\/10-241\/v1\/pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/wellcomeopenresearch.org\/articles\/10-241\/v1\/iparadigms","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,24]],"date-time":"2025-11-24T06:25:08Z","timestamp":1763965508000},"score":1,"resource":{"primary":{"URL":"https:\/\/wellcomeopenresearch.org\/articles\/10-241\/v1"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,5,16]]},"references-count":53,"URL":"https:\/\/doi.org\/10.12688\/wellcomeopenres.21374.1","relation":{"has-review":[{"id-type":"doi","id":"10.21956\/wellcomeopenres.23639.r139279","asserted-by":"subject"},{"id-type":"doi","id":"10.21956\/wellcomeopenres.23639.r124646","asserted-by":"subject"},{"id-type":"doi","id":"10.21956\/wellcomeopenres.23639.r139279","asserted-by":"object"},{"id-type":"doi","id":"10.21956\/wellcomeopenres.23639.r124646","asserted-by":"object"}]},"ISSN":["2398-502X"],"issn-type":[{"value":"2398-502X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,5,16]]},"assertion":[{"value":"Indexed","URL":"https:\/\/wellcomeopenresearch.org\/articles\/10-241\/v1#article-reports","order":0,"name":"referee-status","label":"Referee status","group":{"name":"current-referee-status","label":"Current Referee Status"}},{"value":"10.21956\/wellcomeopenres.23639.r124646, Anand Krishnan, All India Institute of Medical Sciences, New Delhi, 23 Aug 2025, version 1, indexed","URL":"https:\/\/wellcomeopenresearch.org\/articles\/10-241\/v1#referee-response-124646","order":0,"name":"referee-response-124646","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.21956\/wellcomeopenres.23639.r139279, Jazlan Jamaluddin, Universiti Malaya, Kuala Lumpur, Federal Territory of Kuala Lumpur, 24 Nov 2025, version 1, indexed","URL":"https:\/\/wellcomeopenresearch.org\/articles\/10-241\/v1#referee-response-139279","order":1,"name":"referee-response-139279","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"This work was supported by Wellcome [107768]; the Consortium for Advanced Research Training in Africa (CARTA), jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York [G-19-57145]; Sida [54100113]; Uppsala Monitoring Center, Norwegian Agency for Development Cooperation (Norad); and the UK Foreign, Commonwealth & Development Office, with support from the Developing Excellence in Leadership, Training and Science in Africa (DELTAS Africa) programme. The first author also received support from National Heart, Lung, And Blood Institute of the National Institutes of Health [U24HL136791], through the NCD BRITE consortium. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders. The statements made and views expressed are solely the responsibility of the Fellow. For the purpose of open access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.","order":2,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}