The influence of gender on the primary care management of diabetes in Tunisia

BACKGROUND: Gender differences in access to high quality care for chronic illnesses have been suggested yet little work in this potentially vital area of health care inequality has been undertaken in Africa. We explored the influence of patient gender on the care of people with diabetes within a multi-method, national study of diabetes management in primary care in Tunisia. METHODS: Methodologies used were quantitative (nationwide randomized study of 2160 medical records) and qualitative (participant observation, focus groups and interviews of patients and health care professionals). RESULTS: Differences in patient characteristics, treatments prescribed, process and outcome data and access to care variables were demonstrated. The most striking disparity found was the high female to male ratio of patients attending for diabetes care (61.1%). A number of possible explanations for this emerged: Men were thought to under-attend for practical, financial and behavioural reasons whereas women were thought to have increased morbidity and potentially over-attend for social and psychological reasons. CONCLUSION: We have demonstrated a number of disparities in the care of men and women with diabetes in Tunisian primary care. In particular, a dual but related problem emerges from the data: more women than men attend for diabetes care and yet women do not get the same level of risk factor control as men. A number of local explanations for these disparities have emerged, which inform our analysis of the impact of gendered beliefs on diabetes care. Strategies to address these disparities will require a careful consideration of local beliefs and practices.