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The paper by Brown et al.1 is an important insight into the contextual facilitators and barriers involved in the management of patients with type 2 diabetes mellitus. Research into this often neglected area must now intensify and extend into all cultures worldwide. In Tunisia, the number of patients with diabetes has more than doubled in the last two decades.2,3 We currently are undertaking a study exploring the factors that affect the management of patients with diabetes in primary care in the public sector in Tunis. From a variety of sources (medical records, formal interviews, discussions, observation and reflection), we have discovered .80 potential facilitators and barriers to care, and, like Brown et al. suggest, many of these factors interact closely with one another. The most frequently noted factors are availability of specialists, laboratory facilities and medical supplies, the quality of the medical files used, the motivation of the physicians, and patient adherence. Many of these factors have been noted in previous studies in the western world, but a number of additional factors also appear to be important and warrant further study: (i) the patients understanding of ‘sokkor’ (‘diabetes’, literally translated as ‘sugar’) and their use of traditional healers; (ii) the availability and performance of medical supplies and equipment; (iii) the motivation of other health centre staff, as well as the physician; and (iv) the ‘culture’ and underlying philosophy of each individual health centre. Further exploration of the factors that prevent effective implementation of chronic disease management guidelines in primary care around the world is crucial:

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‘Sokkor’: research into the contextual facilitators barriers involved in the management of patients with type 2 diabetes mellitus must now intensify extend into all cultures worldwide