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1.  How diabetic patients' ideas of illness course affect non-adherent behaviour: a qualitative study 
Type 2 diabetes is becoming more prevalent and its successful management relies on patients' self-care behaviours. Measures focusing on patients' perceptions can be effective behavioural interventions.
To gain insight into the perceptions of patients with diabetes, especially ideas of the illness course and perceived severity, and their impacts on self-care behaviour.
Design of study
Qualitative approach with in-depth patient interviews (n = 22) and seven focus groups (n = 53).
A rural town in Taiwan.
The interview protocol was mainly derived from Kleinman's explanatory model. Purposive sampling strategies of maximum variation were used. The transcript of the interviews was analysed with editing and immersion/crystallisation styles.
Diabetes is regarded as an incurable, inevitably deteriorating disorder of sugar metabolism with many chronic complications. Patients thought that renal injury, followed by blindness, leg amputation, and poor peripheral circulation, were the most frequent complications. They also assessed their perceived severity of the disease at specific points in time through different indicators in their daily lives, such as sugar level, presence of complications, and medications used. Patients felt that these aspects progressed concurrently and that the illness course followed a unidimensional process. The ever-increasing doses of medication was considered by these patients to be a side-effect of the drugs taken.
Physicians should clarify with their patients that the risks of uraemia, blindness, and leg amputation are less prevalent than expected and that patients should pay more attention to cardiovascular complications. Certain oral hypoglycaemic agents may not cause a vicious cycle of ever-increasing doses of medication and the drugs that need to be taken should not be seen as indicators of severity but, rather, measures taken to prevent the diabetes becoming severe in the future.
PMCID: PMC2043347  PMID: 17394733
cognition; illness course; patient non-adherence; qualitative research; severity of illness; type 2 diabetes
2.  Self-management of type 2 diabetes mellitus: a qualitative investigation from the perspective of participants in a nurse-led, shared-care programme in the Netherlands 
BMC Public Health  2008;8:91.
Diabetes mellitus is a major public health problem. Little is known about how people with type 2 diabetes experience self-management in a nurse-led, shared-care programme. The purpose of this article is to report an empirically grounded conceptualization of self-management in the context of autonomy of people with type 2 diabetes.
This study has a qualitative descriptive, and exploratory design with an inductive approach. Data were collected by means of in-depth interviews. The sample consisted of older adults with type 2 diabetes in a nurse-led, shared-care setting. The data analysis was completed by applying the constant comparative analysis as recommended in grounded theory.
People with type 2 diabetes use three kinds of self-management processes: daily, off-course, and preventive. The steps for daily self-management are adhering, adapting, and acting routinely. The steps for off-course self-management are becoming aware, reasoning, deciding, acting, and evaluating. The steps for preventive self-management are experiencing, learning, being cautious, and putting into practice. These processes are interwoven and recurring.
Self-management consists of a complex and dynamic set of processes and it is deeply embedded in one's unique life situation. Support from diabetes specialist nurses and family caregivers is a necessity of self-managing diabetes.
PMCID: PMC2292711  PMID: 18366665
3.  Adherence to diabetes self-care behaviors in English- and Spanish-speaking Hispanic men 
We conducted a qualitative study to elicit attitudes, attributions, and self-efficacy related to diabetes self-care in both English- and Spanish-speaking Hispanic men. Transcripts from six focus groups (three in English and three in Spanish) were reviewed by the authors to extract principal and secondary themes. Participants could describe their medication and lifestyle regimens and were aware of whether they were adherent or nonadherent to physician recommendations. Lack of skills on how to incorporate diet and regular physical activity into daily living, lack of will power, and reluctance to change culturally rooted behaviors emerged as significant barriers to diabetes self-management. Medication adherence is for some men the principal diabetes self-care behavior. Nonadherence appeared to fit two profiles: 1) intentional, and 2) nonintentional. In both instances low self-efficacy emerged as a significant influence on attainment and maintenance of diabetes self-care goals. Participants also expressed a strong sense of fatalism regarding the course of their disease, and seemed to have little motivation to attempt long-term dietary control. Educational and counseling messages should stress that a diagnosis of diabetes is not a death sentence, and full functional capacity can be maintained with good control.
PMCID: PMC2778413  PMID: 19936154
type 2 diabetes; self-care; glycemic control; adherence
4.  Associations between Coping, Diabetes Knowledge, Medication Adherence, and Self-Care Behaviors in Adults with Type 2 Diabetes 
General Hospital Psychiatry  2012;34(4):385-389.
Few studies have examined the emotional approach to coping on diabetes outcomes. This study examined the relationship between emotional coping and diabetes knowledge, medication adherence, and self-care behaviors in adults with type 2 diabetes.
Data on 378 subjects with type 2 diabetes recruited from two primary care clinics in the Southeastern United States were examined. Previously validated scales were used to measure coping, medication adherence, diabetes knowledge, and diabetes self-care behaviors (including diet, physical activity, blood sugar testing and foot care). Multiple linear regression was used to assess the independent effect of coping through emotional approach on medication adherence and self-care behaviors while controlling for relevant covariates.
Significant correlations were observed between emotional coping (as measured by emotional expression (EE) and emotional processing (EP)) and self-care behaviors. In the linear regression model, EP was significantly associated with medication adherence (β −0.17, 95% CI −0.32 to −0.015), diabetes knowledge (β 0.76, 95% CI 0.29 to 1.24), diet (β 0.52, 95% CI 0.24 to 0.81), exercise (β 0.51, 95% CI 0.19 to 0.82), blood sugar testing (β 0.54, 95% CI 0.16 to 0.91), and foot care (β 0.32, 95% CI −0.02 to 0.67). On the other hand, EE was associated with diet (β 0.38, 95% CI 0.13 to 0.64), exercise (β 0.54, 95% CI 0.27 to 0.82), blood sugar testing (β 0.42, 95% CI 0.09 to 0.76) and foot care (β 0.36, 95% CI 0.06 to 0.66), but it was not associated with diabetes knowledge.
These findings indicate that coping through an emotional approach is significantly associated with behaviors that lead to positive diabetes outcomes.
PMCID: PMC3383912  PMID: 22554428
Coping; medication adherence; self-care; diabetes
5.  Alcohol use of diabetes patients: The need for assessment and intervention 
Acta diabetologica  2010;50(2):93-99.
It is well known that diabetes self-care behaviors are critical to disease progression. Unfortunately, many patients do not adhere to diabetes self-care recommendations despite their importance. Alcohol use has been identified as a barrier to diabetes self-care adherence. Excessive alcohol consumption not only negatively impacts diabetes self-care adherence but also affects the course of diabetes. Diabetes patients who are at-risk drinkers are likely to have poor diabetes treatment adherence, leading to increased morbidity and mortality. Alcohol consumption by diabetes patients is often inadequately assessed and addressed in their medical care. Brief interventions to reduce at-risk drinking have been well validated in a variety of patient populations and offer the potential to improve diabetes treatment adherence and outcome. Assessment and treatment of at-risk drinking could be readily incorporated into routine diabetes care. Strategies for brief assessment of and intervention for at-risk drinking are offered.
PMCID: PMC2954251  PMID: 20532803
Alcohol use; diabetes; alcohol assessment; brief intervention; at-risk drinking; self-care adherence
6.  Barriers and facilitating factors for disease self-management: a qualitative analysis of perceptions of patients receiving care for type 2 diabetes and/or hypertension in San José, Costa Rica and Tuxtla Gutiérrez, Mexico 
BMC Family Practice  2013;14:131.
The burden of cardiovascular disease is growing in the Mesoamerican region. Patients’ disease self-management is an important contributor to control of cardiovascular disease. Few studies have explored factors that facilitate and inhibit disease self-management in patients with type 2 diabetes and hypertension in urban settings in the region. This article presents patients’ perceptions of barriers and facilitating factors to disease self-management, and offers considerations for health care professionals in how to support them.
In 2011, 12 focus groups were conducted with a total of 70 adults with type 2 diabetes and/or hypertension who attended urban public health centers in San José, Costa Rica and Tuxtla Gutiérrez, Chiapas, Mexico. Focus group discussions were transcribed and coded using a content analysis approach to identify themes. Themes were organized using the trans-theoretical model, and other themes that transcend the individual level were also considered.
Patients were at different stages in their readiness-to-change, and barriers and facilitating factors are presented for each stage. Barriers to disease self-management included: not accepting the disease, lack of information about symptoms, vertical communication between providers and patients, difficulty negotiating work and health care commitments, perception of healthy food as expensive or not filling, difficulty adhering to treatment and weight loss plans, additional health complications, and health care becoming monotonous. Factors facilitating disease self-management included: a family member’s positive experience, sense of urgency, accessible health care services and guidance from providers, inclusive communication, and family and community support.
Financial difficulty, gender roles, differences by disease type, faith, and implications for families and their support were identified as cross-cutting themes that may add an additional layer of complexity to disease management at any stage. These factors also relate to the broader family and societal context in which patients live.
People living with type 2 diabetes and hypertension present different barriers and facilitating factors for disease self-management, in part based on their readiness-to-change and also due to the broader context in which they live. Primary care providers can work with individuals to support self-management taking into consideration these different factors and the unique situation of each patient.
PMCID: PMC3846574  PMID: 24007205
Cardiovascular health; Trans-theoretical model; Health promotion; Primary care
7.  The Diabetes Self-Management Questionnaire (DSMQ): development and evaluation of an instrument to assess diabetes self-care activities associated with glycaemic control 
Though several questionnaires on self-care and regimen adherence have been introduced, the evaluations do not always report consistent and substantial correlations with measures of glycaemic control. Small ability to explain variance in HbA1c constitutes a significant limitation of an instrument’s use for scientific purposes as well as clinical practice. In order to assess self-care activities which can predict glycaemic control, the Diabetes Self-Management Questionnaire (DSMQ) was designed.
A 16 item questionnaire to assess self-care activities associated with glycaemic control was developed, based on theoretical considerations and a process of empirical improvements. Four subscales, ‘Glucose Management’ (GM), ‘Dietary Control’ (DC), ‘Physical Activity’ (PA), and ‘Health-Care Use’ (HU), as well as a ‘Sum Scale’ (SS) as a global measure of self-care were derived. To evaluate its psychometric quality, 261 patients with type 1 or 2 diabetes were assessed with the DSMQ and an established analogous scale, the Summary of Diabetes Self-Care Activities Measure (SDSCA). The DSMQ’s item and scale characteristics as well as factorial and convergent validity were analysed, and its convergence with HbA1c was compared to the SDSCA.
The items showed appropriate characteristics (mean item-total-correlation: 0.46 ± 0.12; mean correlation with HbA1c: -0.23 ± 0.09). Overall internal consistency (Cronbach’s alpha) was good (0.84), consistencies of the subscales were acceptable (GM: 0.77; DC: 0.77; PA: 0.76; HU: 0.60). Principal component analysis indicated a four factor structure and confirmed the designed scale structure. Confirmatory factor analysis indicated appropriate fit of the four factor model. The DSMQ scales showed significant convergent correlations with their parallel SDSCA scales (GM: 0.57; DC: 0.52; PA: 0.58; HU: n/a; SS: 0.57) and HbA1c (GM: -0.39; DC: -0.30; PA: -0.15; HU: -0.22; SS: -0.40). All correlations with HbA1c were significantly stronger than those obtained with the SDSCA.
This study provides preliminary evidence that the DSMQ is a reliable and valid instrument and enables an efficient assessment of self-care behaviours associated with glycaemic control. The questionnaire should be valuable for scientific analyses as well as clinical use in both type 1 and type 2 diabetes patients.
PMCID: PMC3751743  PMID: 23937988
Diabetes care; Self-management; Self-care behaviour; Metabolic control; HbA1c; Hyperglycaemia; Measurement; Assessment; Psychometric instrument
8.  Relationships between locus of control and adherence to diabetes regimen in a sample of Iranians 
Adequate self-care in diabetes improves quality of life and decreases the number of inpatient cases. The health locus of control theory is used to assess adherence to diabetes regimen in some studies in developed countries. The primary purpose of this cross-sectional study is to determine the status of diabetes locus of control in a sample of diabetic patients in Iran as a developing country. We investigated selected factors contributing to locus of control and adherence to diabetes regimen.
Materials and Methods:
This cross-sectional study was carried out on 120 patients referred to Yazd Diabetes Research Center. The Iranian versions of Diabetes Locus of Control scale and Diabetes Self-care Activities scale were used for data collection.
Men revealed more internal locus of control and women revealed more chance locus of control. The attributions of external locus of control increased by age, while the internal locus of control increased by education level and chance locus of control decreased by education level. A positive association between internal locus of control and adherence to diabetes regimen was found and there was a negative association between chance locus of control and adherence to diabetes regimen.
Findings suggest that interventions aimed at improving internal locus of control may improve adherence to diabetes regimen but different diabetic patients have different attribution styles and interventional programs to enhance diabetes self-care will be more successful if patient's locus of control is addressed.
PMCID: PMC2859281  PMID: 20431803
Adherence to diabetes regimen; locus of control; Iran
9.  Self-reported Neighborhood Safety and Nonadherence to Treatment Regimens Among Patients with Type 2 Diabetes 
Few studies have explored the association between neighborhood characteristics and adherence to diabetes self-management behaviors, and none have examined the influence of neighborhood safety on adherence to treatment regimens among patients with diabetes.
To assess whether neighborhood safety is associated with self-reports of technical quality of care and with nonadherence to diabetes treatment regimens.
A cross-sectional analysis of a population-based sample of California adults responding to the 2007 California Health Interview Survey. Multivariable logistic regression models were used to examine the association of self-reported neighborhood safety with technical quality of care and treatment nonadherence, adjusted for sociodemographic characteristics, barriers to access to care, and health status.
Adults with type 2 diabetes currently receiving medical treatment.
Patient-reported neighborhood safety, performance of recommended processes of care by provider, treatment nonadherence (patient delays in filling prescriptions and obtaining needed medical care).
Self-reported neighborhood safety was not associated with process measures of technical quality of care, but was associated with treatment nonadherence. Specifically, compared to those who report living in a safe neighborhood, a higher proportion of patients living in unsafe neighborhoods reported delays in filling a prescription for any reason (21.9% vs. 12.8%, aOR = 1.69, 95%CI 1.19, 2.40) and delays in filling a prescription due to cost (12.2% vs. 6.8%, aOR = 1.63, 95%CI 1.02, 2.62).
Contextual factors, such as neighborhood safety, may contribute to treatment nonadherence in daily life, even when the technical quality of care delivered in the clinic is not diminished.
PMCID: PMC3286552  PMID: 21935749
diabetes; adherence to treatment regimens; neighborhood safety
10.  Evaluation of self-care practices and relative components among type 2 diabetic patients 
The purpose of this study was to assess self-care practices and their relative components among type 2 diabetic patients. We hypothesized that some sociodemographic and health-related factors, high diabetes distress, and low self-efficacy would be associated with poorer self-care practices.
Materials and Methods:
A cross-sectional study was conducted for a period of 6 months in 2011. Study population was type 2 diabetic patients referring to Omolbanin center, an outpatient diabetic center in Isfahan. One hundred forty diabetic patients met the inclusion criteria and were all included in the study. Patients’ self-care practices were measured by Summary of Diabetes Self-care Activities (SDSCA) self-report scale that includes items on the following aspects of the diabetes regimen: General diet, specific diet, exercise, blood glucose testing, foot care, medications, and smoking. Diabetes distress measured by Diabetes Distress Scale (DDS) scale and Stanford diabetes self-efficacy scale was used for scoring this issue. Collected data were analyzed by using SPSS software version 11.5.
Participants were between the ages of 37 and 75 years, with a mean of 53.23 years (SD=7.82). Fifty-four percent (n=76) were females; 97.1% were married (n=136), and 53.6% had education lower than diploma (n=75). Mean of duration of diabetes was 7.1 (SD=5.63) years. “Medications” subscale was considered as the most important one in measuring diabetes self-care practices (5.24 ± 2.38 days/week). Study findings revealed that general diet had significant relation with comorbidity, type of treatment, body mass index (BMI), fasting blood sugar (FBS), (Blood Sugar) (BS), waist circumference, diabetes distress, and self-efficacy. Specific diet had significant relation with comorbidity, education, triglyceride (TG), diastolic blood pressure (DBP), and low density lipoprotein (LDL). Exercise showed significant relation with history of diabetes, education, type of treatment, disease duration, TG, BMI, and BS. Also, blood glucose testing showed significant relation with disease duration, self-efficacy, TG, DBP, BS, LDL, and high density lipoprotein (HDL). On the other hand, foot care was related to age, diabetes distress, TG, BMI, HDL, and diabetes complications. Medications subscale as the most important subscale of self-care practices was relevant with age, disease duration, diabetes complications, type of treatment, FBS, HDL, and self-efficacy. The last subscale, smoking, had significant relation with sex, diabetes complications, diabetes distress, self-efficacy, TG, total cholesterol, BS, and HDL.
This information should be used in clinical practice when targeting and designing educational and care plan for patients with type 2 diabetes.
PMCID: PMC3577380  PMID: 23555122
Diabetes distress; self-care; self-efficacy; type 2 diabetes
11.  Experiences and needs of diabetic patients and healthcare professionals: a qualitative study in the canton of Vaud (Switzerland) 
To explore the needs and expectations of diabetic patients and healthcare professionals in the canton of Vaud.
Development and implementation of a diabetes cantonal program.
We conducted one focus group (FG) with diabetic patients and one with healthcare professionals (general practitioners, diabetologists, pharmacists, home healthcare managers, podologists) in each of the four health regions of the canton (n=8 FG). FGs were audio-taped and transcribed verbatim, and content analysis performed.
Results and conclusion
Perceived quality of diabetes care varies, depending on participants and regions considered. Participants describe a lack of collaboration and communication between professionals, problems linked to self-management education, and a lack of information on diabetes for the general population.
They propose to improve the quality of care by strengthening existing structures, by developing centralization of care and information, and by reinforcing teamwork and self-management education. They also suggest implementing information and prevention campaigns for the general population.
Diabetics and healthcare professionals express the need to develop a cantonal program at a local level and adapted to patients’ needs. For patients, such a program would represent an opportunity to have access to comprehensive care. For healthcare professionals, it would favor the development of teamwork and of local networks.
Participants point out similar problems and solutions, even if not similarly expressed. These results should help the development and implementation of a program adapted to the patients’ and professionals’ needs.
PMCID: PMC3184830
diabetes; chronic disease management; qualitative methods; Switzerland
12.  Health care professionals meeting with individuals with Type 2 diabetes and obesity: Balancing coaching and caution 
The burden of diabetes and obesity is increasing worldwide, indicating a need to find the best standard for diabetes care. The aim of this study was to generate a theory grounded in empirical data derived from a deeper understanding of health care professionals’ main concerns when they consult with individuals with diabetes and obesity and how they handle these concerns. Tape-recorded interviews were conducted with seven groups and three individual members of a diabetes team in an area of western Sweden. The grounded theory (GT) method was used to analyse the transcribed interviews. A core category, labelled Balancing coaching and caution and three categories (Coaching and supporting, Ambivalence and uncertainty, and Adjusting intentions) emerged. The core category and the three categories formed a substantive theory that explained and illuminated how health care professionals manage their main concern; their ambition to give professional individualised care; and find the right strategy for each individual with diabetes and obesity. The theory generated by this study can improve our understanding of how a lack of workable strategies limits caregivers’ abilities to reach their goals. It also helps identify the factors that contribute to the complexity of meetings between caregivers and individuals with diabetes.
PMCID: PMC3133454  PMID: 21750687
Care meeting; coaching; diabetes Type 2; grounded theory; health care professional; obesity
13.  Effectiveness of a group diabetes education programme in underserved communities in South Africa: pragmatic cluster randomized control trial 
BMC Family Practice  2012;13:126.
Diabetes is an important contributor to the burden of disease in South Africa and prevalence rates as high as 33% have been recorded in Cape Town. Previous studies show that quality of care and health outcomes are poor. The development of an effective education programme should impact on self-care, lifestyle change and adherence to medication; and lead to better control of diabetes, fewer complications and better quality of life.
Trial design: Pragmatic cluster randomized controlled trial
Participants: Type 2 diabetic patients attending 45 public sector community health centres in Cape Town
Interventions: The intervention group will receive 4 sessions of group diabetes education delivered by a health promotion officer in a guiding style. The control group will receive usual care which consists of ad hoc advice during consultations and occasional educational talks in the waiting room.
Objective: To evaluate the effectiveness of the group diabetes education programme
Outcomes: Primary outcomes: diabetes self-care activities, 5% weight loss, 1% reduction in HbA1c. Secondary outcomes: self-efficacy, locus of control, mean blood pressure, mean weight loss, mean waist circumference, mean HbA1c, mean total cholesterol, quality of life
Randomisation: Computer generated random numbers
Blinding: Patients, health promoters and research assistants could not be blinded to the health centre’s allocation
Numbers randomized: Seventeen health centres (34 in total) will be randomly assigned to either control or intervention groups. A sample size of 1360 patients in 34 clusters of 40 patients will give a power of 80% to detect the primary outcomes with 5% precision. Altogether 720 patients were recruited in the intervention arm and 850 in the control arm giving a total of 1570.
The study will inform policy makers and managers of the district health system, particularly in low to middle income countries, if this programme can be implemented more widely.
Trial register
Pan African Clinical Trial Registry PACTR201205000380384
PMCID: PMC3560091  PMID: 23265076
Diabetes; Group education; Health education; Motivational interviewing; Mid-level health workers; South Africa; Primary care
14.  Non-adherence to self-care practices & medication and health related quality of life among patients with type 2 diabetes: a cross-sectional study 
BMC Public Health  2014;14:431.
Non-adherence to lifestyle modification among diabetic patients develops the short-term risks and the long-term complications as well as declines the quality of life. This study aimed to find out the association between non-adherence to self-care practices, medication and health related quality of life (HR-QoL) among type 2 diabetic patients.
At least 1 year diagnosed patients with type 2 diabetes (N = 500), age>25 years were conveniently selected from the Out-Patient Department of Bangladesh Institute of Health Sciences Hospital. Patients’ self-care practices were assessed via interviewer-administered questionnaires using an analytical cross-sectional design. HRQoL was assessed by an adapted and validated Bangla version of the EQ-5D (EuroQol Group, 2009) questionnaire which has five domains- mobility, self-care, usual activities, pain/discomfort and anxiety/depression and two levels on each dimension. EQ-5D responses were further translated into single summery EQ-5D index using UK TTO value set. Patients’ were considered as non-adhered to self-care practices according to the guidelines of Diabetic Association of Bangladesh. Multivariable linear regression was used to assess the association between non-adherence towards self-care practices and HRQoL.
Among the study patients, 50.2% were females and mean ± SD age was 54.2 (±11.2) years. Non-adherence rate were assessed for: blood glucose monitoring (37%), diet (44.8%), foot care (43.2%), exercise (33.2%) and smoking (37.2%). About 50.4% patients had problem in mobility, 28.2% in self-care, 47.6% in usual activities, 72.8% in pain/discomfort and 73.6% in anxiety/depression. On chi-squared test, significant association was found between non adherence to foot care and problem with mobility, self-care and usual activities (p < 0.05). Significant association was also found between non-adherence to exercise and poor mobility, self- care, usual activities, pain and anxiety (p < 0.05). Non-adherence to diet was associated with poor mobility (p < 0.05). In multivariable linear regression non-adherence to foot care (p = 0.0001), exercise (p = 0.0001), and smoking (p = 0.047) showed significant association with EQ-5D index after adjusting co-variates.
In this study, patients who have a non-adherence rate also have a lower quality of life.
PMCID: PMC4019601  PMID: 24885315
Non-adherence; Self-care practices; Medication; Health related quality of life; Bangladesh; Type 2 diabetes
15.  Physicians’ Perceptions of the Type 2 Diabetes Multidisciplinary Treatment Team: A Qualitative Study 
The Diabetes educator  2011;37(6):794-800.
The purpose of this study was to explore physicians’ perceptions of the multidisciplinary type 2 diabetes treatment team.
Nineteen physicians (74% endocrinologists; 26% primary care) participated in semi-structured interviews. Audiorecorded data were transcribed, coded, and analyzed using thematic analysis and NVivo 8 software.
Physicians considered the multidisciplinary team, including a physician and diabetes educator, as very important to diabetes treatment. Participants described how diabetes with its many co-morbidities and challenging lifestyle recommendations, is difficult for any single physician to treat. They further described how the team’s diverse staff offers complementary skills and more contact time for assessment and treatment of patients, developing treatment relationships, and supporting patients in learning diabetes self-care. Physicians stressed the necessity of regular and ongoing communication among team members to ensure patients receive consistent information, and some reported that institutional factors interfere with intra-team communication. They also expressed concerns about the team approach in relation to individualized treatment and patients’ reluctance to see multiple providers.
This study highlights physicians’ positive perceptions of and concerns about the type 2 diabetes multidisciplinary team. Further study of diabetes educators’ and patients’ perceptions of the team approach is needed.
PMCID: PMC3707496  PMID: 22002972
type 2 diabetes; treatment team; qualitative research
16.  Social support in type II diabetes care: a case of too little, too late 
Coping with type II diabetic patients is increasingly posing large financial burdens, sorely felt especially by growing economies. Self-management has been found to be an effective approach towards maintaining good control in diabetics. However, although efforts at implementing self-management have had initial success, there has been a lack of sustainability. This review examines the different components impinging on self-care among type II diabetic patients. These include the critical role of social support, the need for support from health care providers, the value of support from family and friends, the influence of sex and cultural factors in self-care behavior, the benefits of peer support, and the role of literacy in diabetes self-care. Despite the mounting evidence for the effectiveness of social support in diabetes care, and the various stakeholders including this in their clinical guidelines, there has only been a lukewarm response from policy-makers towards ensuring its implementation. Hence, more effort is required from health care providers in moving away from just understanding the effects of new drugs and subsequently putting their patients on these drugs, and going back to the basics of communicating with the patients, understanding their woes, and helping to motivate/empower their patients. This paper analyzes the various components of social support, their influence on diabetes self-care, and how health care providers can help in this process.
PMCID: PMC3514066  PMID: 23226028
type II diabetes mellitus; social support; self-management/self-care
17.  The introduction of self-management in Type 2 Diabetes care: A narrative review 
Type 2 diabetes is one of the most life-threatening public health challenges in the world. It causes a high disease burden including increased disability, reduced life expectancy and ever-increasing costs of care in almost every country. The growing burden of diabetes along with rapid cultural changes, aging population, increasing urbanization, changes in nutritional habits, reduced physical activity, and improper lifestyle and behavior patterns would inexorably drive increased health care costs and demands. Several models of education have been proposed to reduce the complications of chronic diseases including diabetes. However, it is widely known and acknowledged that adopting self-care and self-management behaviors play a fundamental role in diabetes control and treatment. A non-systematic (narrative) search strategy was used to collect necessary data. Several models of diabetes care such as compliance-based or curative models exist. Neither the curative model nor the compliance/adherence model is rigorously effective in diabetes care. The model of self-empowerment – based on the three fundamental aspects of chronic illness care: choices, control, and consequences – is much more applicable in the management of diabetes. This point to an approach which recognizes that patients are responsible for their diabetes care. Self-empowerment model has the potential to place diabetes care into context – a context which is based on active involvement of patients and informed, proactive healthcare professionals in the process of care.
PMCID: PMC3577389  PMID: 23555138
Empowerment; model of care; self-care; self-management; type 2 diabetes
18.  Peer-based behavioural strategies to improve chronic disease self-management and clinical outcomes: evidence, logistics, evaluation considerations and needs for future research 
Family Practice  2009;27(Suppl 1):i17-i22.
The diagnosis of a chronic disease such as diabetes generally evokes strong emotions and often brings with it the need to make changes in lifestyle behaviours, such as diet, exercise, medication management and monitoring clinical and metabolic parameters. The diagnosis thus affects not only the person diagnosed but also the family members. Chronic illnesses are largely self-managed with ∼99% of the care becoming the responsibility of patients and their families or others involved in the daily management of their illnesses. While the responsibility for outcomes, such as metabolic control and chronic complications, are shared with the health care team, the daily decisions and behaviours adopted by patients clearly have a strong influence on their future health and well-being. While diabetes self-management education is essential, it is generally not sufficient for patients to sustain behaviours and cope with a lifetime of diabetes. Peers have been proposed as one method for assisting patients to deal with the behavioural and affective components of diabetes and to provide ongoing self-management support.
This paper first describes effective behavioural strategies in diabetes, based on multiple studies and/or meta-analyses, and then provides examples of their use by peers or in peer-based programmes in diabetes. A comprehensive search using the MEDLINE® and Cinahl databases was conducted. Key search terms included peer mentors, peer leaders, peer educators, lay health workers and community health workers. Studies that clearly identified behavioural strategies used by peers were included.
PMCID: PMC2873176  PMID: 19509083
behaviour change; diabetes; lay health workers; social support
19.  Diabetes Self-Management and Education of People Living with Diabetes: A Survey in Primary Health Care in Muscat Oman 
PLoS ONE  2013;8(2):e57400.
Although the prevalence of type 2 diabetes in Oman is high and rising, information on how people were self-managing their disease has been lacking. The objective of this study was therefore to assess diabetes self-management and education (DSME) among people living with type 2 diabetes in Oman.
A questionnaire survey was conducted in public primary health care centres in Muscat. Diabetes self-management and education was assessed by asking how patients recognized and responded to hypo- and hyperglycaemia, and if they had developed strategies to maintain stable blood glucose levels. Patients' demographic information, self-treatment behaviours, awareness of potential long-term complications, and attitudes concerning diabetes management were also recorded. Associations between these factors and diabetes self-management and education were analysed.
In total, 309 patients were surveyed. A quarter (26%, n = 83) were unaware how to recognize hypoglycaemia or respond to it (26%, n = 81). Around half (49%, n = 151), could not recognize hyperglycaemia and more than half could not respond to it (60%, n = 184). Twelve percent (n = 37) of the patients did not have any strategies to stabilize their blood glucose levels. Patients with formal education generally had more diabetes self-management and education than those without (p<0.001), as had patients with longer durations of diabetes (p<0.01). Self-monitoring of blood glucose was practiced by 38% (n = 117) of the patients, and insulin was used by 22% (n = 67), of which about one third independently adjusted dosages. Patients were most often aware of complications concerning loss of vision, renal failure and cardiac problems. Many patients desired further health education.
Many patients displayed dangerous diabetes self-management and education knowledge gaps. The findings suggest a need for improving knowledge transfer to people living with diabetes in the Omani clinical setting.
PMCID: PMC3579849  PMID: 23451219
20.  Primary care nurses struggle with lifestyle counseling in diabetes care: a qualitative analysis 
BMC Family Practice  2010;11:41.
Patient outcomes are poorly affected by lifestyle advice in general practice. Promoting lifestyle behavior change require that nurses shift from simple advice giving to a more counseling-based approach. The current study examines which barriers nurses encounter in lifestyle counseling to patients with type 2 diabetes. Based on this information we will develop an implementation strategy to improve lifestyle behavior change in general practice.
In a qualitative semi-structured study, twelve in-depth interviews took place with nurses in Dutch general practices involved in diabetes care. Specific barriers in counseling patients with type 2 diabetes about diet, physical activity, and smoking cessation were addressed. The nurses were invited to reflect on barriers at the patient and practice levels, but mainly on their own roles as counselors. All interviews were audio-recorded and transcribed. The data were analyzed with the aid of a predetermined framework.
Nurses felt most barriers on the level of the patient; patients had limited knowledge of a healthy lifestyle and limited insight into their own behavior, and they lacked the motivation to modify their lifestyles or the discipline to maintain an improved lifestyle. Furthermore, nurses reported lack of counseling skills and insufficient time as barriers in effective lifestyle counseling.
The traditional health education approach is still predominant in primary care of patients with type 2 diabetes. An implementation strategy based on motivational interviewing can help to overcome 'jumping ahead of the patient' and promotes skills in lifestyle behavioral change. We will train our nurses in agenda setting to structure the consultation based on prioritizing the behavior change and will help them to develop social maps that contain information on local exercise programs.
PMCID: PMC2889883  PMID: 20500841
21.  Improving of Type 2 Diabetic Patients’ Knowledge, Attitude and Practice Towards Diabetes Self-care by Implementing Community-Based Interactive Approach-Diabetes Mellitus Strategy 
BMC Research Notes  2012;5:315.
Community Based Interactive Approach-diabetes mellitus (CBIA-DM) is an active self-learning method. This study is aimed at improving type 2 diabetic patients' knowledge, attitude and practice on diabetes self-care by implementing the CBIA-DM strategy. Time series, pre and post quasi-experimental design, Intervention group underwent CBIA-DM, DM-club and Normal-care group acted as control. Data were collected in pre-intervention, immediately, one, three and six months post intervention. Ranging scores for pre and post test questionnaires were: knowledge (0–18) and attitude (9–45); categorizing as rational scales of the scores in good, fair and poor. Practicing in diabetes self-care was assessed using 12 questionnaires, and categorized as adhere and not adhere to DM self-care. Effectiveness of CBIA-DM was evaluated based on the increasing number of participants in good knowledge and attitude levels, and adherence in practicing diabetes self-care.
CBIA-DM group shows increasing number of participants in good level of knowledge from 40 % (n = 30) up to 80 % at M + 3 with scores significantly improved from 13.1 ± 2.4 up to 15.4 ± 2.0 (Wilcoxon test, p < 0.05), attitude from 20 % up to 50 % at M + 3, with scores significantly improved from 33.5 ± 4.1 up to 34.9 ± 6.2 (p = 0.031) and increasing number of participants’ adherence to all variables of DM self-care at M + 6 post intervention.
CBIA-DM strategy is effective to improve diabetic patients’ knowledge, attitude and practice on diabetes self-care. Repeating and improving the strategy program is needed to sustain the impact.
PMCID: PMC3424141  PMID: 22721433
CBIA-DM; Diabetes mellitus; KAP; Public education; Small group discussion
22.  Effect of Diabetes Fatalism on Medication Adherence and Self-Care Behaviors in Adults with Diabetes 
General hospital psychiatry  2012;34(6):598-603.
Diabetes fatalism is defined as “a complex psychological cycle characterized by perceptions of despair, hopelessness, and powerlessness” and associated with poor glycemic control. This study examined the association between diabetes fatalism and medication adherence and self-care behaviors in adults with diabetes.
Data on 378 subjects with type 2 diabetes recruited from two primary care clinics in the Southeastern United States were examined. Previously validated scales were used to measure diabetes fatalism, medication adherence, diabetes knowledge, and diabetes self-care behaviors (diet, physical activity, blood sugar testing and foot care). Multiple linear regression was used to assess the independent effect of diabetes fatalism on medication adherence and self-care behaviors controlling for relevant covariates.
Fatalism correlated significantly with medication adherence (r = 0.24, p<0.001), diet (r = −0.26, p<0.001), exercise (r = −0.20, p<0.001) and blood sugar testing (r = −0.19, p<0.001). In the linear regression model, diabetes fatalism was significantly associated with medication adherence (β= 0.029, 95% CI 0.016, 0.043); diabetes knowledge (β= −0.042, 95% CI −0.001, −0.084); diet (β= −0.063, 95% CI −0.039, −0.087), exercise (β= −0.055, 95% CI −0.028, −0.083), and blood sugar testing (β= −0.055, 95% CI −0.023, −0.087). There was no significant association between diabetes fatalism and foot care (β= −0.018, 95% CI −0.047, 0.011). The association between diabetes fatalism and medication adherence, diabetes knowledge and diabetes self-care behaviors did not change significantly when depression was added to the models, suggesting that the associations are independent of depression.
Diabetes fatalism is associated with poor medication adherence and self-care and may be an important target for education and skills interventions in diabetes care. In addition, the effect of diabetes fatalism is independent of depression, suggesting that interventions that target depression may not be sufficient to deal with diabetes fatalism.
PMCID: PMC3479321  PMID: 22898447
fatalism; medication adherence; self-care; diabetes
23.  Adherence in adults with type 1 diabetes mellitus correlates with treatment satisfaction but not with adverse events 
Diabetes self-care and self-monitoring adherence has a positive effect on the metabolic control of the disease. The aim of this study was to analyze the adherence to self-care recommendations and to identify its correlates in adults with type 1 diabetes mellitus.
Patients and methods
One hundred and eleven patients with type 1 diabetes were enrolled in an observational cross-sectional study conducted at the Diabetes Center of the University Hospital in Hradec Králové, Czech Republic. Diabetes self-care adherence was measured by the Self Care Inventory-Revised, and treatment satisfaction by the Diabetes Treatment Satisfaction Questionnaire-status version. Additional data were collected from self-administered questionnaires and medical records. The Mann–Whitney test, Spearman correlations, and multiple linear regressions were used in the statistical analysis.
The mean age of patients was 42.4 years; 59.5% of them were females and 53.2% of all patients used an insulin pump. The mean glycosylated hemoglobin (HbA1c) was 66.2 ± 15.3 mmol/mol and the mean insulin dosage was 0.6 ± 0.3 IU insulin/kg/day. The number of hypoglycemic episodes (including severe) that patients had in the last month before taking the survey was 3.6 ± 3.2. Self-care adherence was associated with treatment satisfaction (0.495; P = 0.004) along with frequency of self-monitoring of before meal blood glucose (0.267; P = 0.003). It was not associated with the incidence of hypoglycemic events or any other insulin therapy-related problems or with socio-demographic or clinical characteristics.
Treatment satisfaction is one of the key factors that need to be targeted to maximize benefits to patients. Self-care adherence in adults with type 1 diabetes did not correlate with socio-demographic and clinical characteristics, nor with adverse events.
PMCID: PMC3772756  PMID: 24043930
treatment adherence; self-care inventory revised; diabetes treatment satisfaction questionnaire; self-monitoring
24.  Sustaining modified behaviours learnt in a diabetes prevention program in regional Australia: the role of social context 
The Greater Green Triangle diabetes prevention program was conducted in primary health care setting of Victoria and South Australia in 2004–2006. This program demonstrated significant reductions in diabetes risk factors which were largely sustained at 18 month follow-up. The theoretical model utilised in this program achieved its outcomes through improvements in coping self-efficacy and planning. Previous evaluations have concentrated on the behavioural components of the intervention. Other variables external to the main research design may have contributed to the success factors but have yet to be identified. The objective of this evaluation was to identify the extent to which participants in a diabetes prevention program sustained lifestyle changes several years after completing the program and to identify contextual factors that contributed to sustaining changes.
A qualitative evaluation was conducted. Five focus groups were held with people who had completed a diabetes prevention program, several years later to assess the degree to which they had sustained program strategies and to identify contributing factors.
Participants value the recruitment strategy. Involvement in their own risk assessment was a strong motivator. Learning new skills gave participants a sense of empowerment. Receiving regular pathology reports was a means of self-assessment and a motivator to continue. Strong family and community support contributed to personal motivation and sustained practice.
Family and local community supports constitute the contextual variables reported to contribute to sustained motivation after the program was completed. Behaviour modification programs can incorporate strategies to ensure these factors are recognised and if necessary, strengthened at the local level.
PMCID: PMC3575269  PMID: 23241135
Diabetes prevention; Evaluation; Social context; Self-efficacy; Volition; Qualitative method
25.  Patient Understanding of Diabetes Self-Management: Participatory Decision-Making in Diabetes Care 
Our aim was to determine whether patient participation in decision-making about diabetes care is associated with understanding of diabetes self-management and subsequent self-care practices. We also identified issues that would impact messaging for use in mobile diabetes communication.
Research Design and Methods:
A cross-sectional observational study was conducted with type 2 diabetes patients (n = 81) receiving their care at the University of Maryland Joslin Diabetes Center. A convenience sample of patients were eligible to participate if they were aged 25–85 years, had type 2 diabetes, spoke English, and visited their physician diabetes manager within the past 6 months. In-person patient interviews were conducted at the time of clinic visits to assess patient understanding of diabetes management, self-care practices, and perceptions of participation in decision-making about diabetes care.
African Americans reported fewer opportunities to participate in decision-making than Caucasians, after controlling for education [mean difference (MD) = -2.4, p = .02]. This association became insignificant after controlling for patient–physician race concordance (MD = -1.5, p = .21). Patient understanding of self-care was predicted by having greater than high school education (MD = 3.6, p = .001) and having physicians who involved them in decision-making about their care. For each unit increase in understanding of diabetes self-care, the mean patient self-care practice score increased by 0.16 (p = .003), after adjustment for patient race and education.
Patient participation in decision-making is associated with better understanding of care. Participation in decision-making plays a key role in patient understanding of diabetes self-management and subsequent self-care practices. Patients with limited education need specific instruction in foot care, food choices, and monitoring hemoglobin A1c.
PMCID: PMC3192639  PMID: 21722588
literacy; mobile; participatory; self-care

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