Motivation: key to a healthy lifestyle in people with diabetes? Current and emerging knowledge and applications

Dietary counselling to increase soluble fibre in patients with gynaecological cancers undergoing pelvic radiotherapy: A feasibility study

BACKGROUND

This study aimed to determine the feasibility of increasing soluble fibre intake via dietary counselling to improve gastrointestinal toxicity and quality of life in patients with gynaecological cancers undergoing pelvic radiotherapy without adverse consequences on radiation treatment (RT) delivery accuracy.

METHODS

A single-arm, single-centre intervention feasibility trial included patients with gynaecological cancers undergoing pelvic RT ± chemotherapy at a tertiary hospital. Participants were provided weekly dietary counselling over the duration of their RT (5-6 weeks) to increase soluble fibre intake incrementally each week. Stakeholder surveys were also completed.

RESULTS

In total, 9 of 14 eligible patients participated (55 years old [SD 13.2], diagnosis: cervical [n = 3], endometrial/uterine [n = 5] and vaginal [n = 1]), with the majority categorised as low fibre consumers at baseline (n = 6). On average, soluble fibre intake increased by 150% throughout treatment. There were no adverse events or major adjustments required for RT delivery. There were improving trends in the functional subset identified. Results may be confounded by the sample size resulting from limited eligibility (n = 14) and a high attrition rate (n = 4).

CONCLUSIONS

Most participants successfully increased their soluble fibre intake throughout treatment, without significant adverse events noted for RT delivery accuracy. These results provide preliminary data to calculate the sample size required to produce meaningful effect sizes. However, this study highlighted challenges in participant recruitment and retention, with limited organisational support and perceived compatibility.

Factors influencing type 2 diabetes self-management practices in rural Bangladesh: a qualitative investigation

Introduction

Type 2 diabetes mellitus (T2DM) is a prevalent, chronic health condition of global significance, with low- and middle-income countries (LMICs) disproportionately affected. Diabetes self-management practices (DSMP) are the gold-standard treatment approach, yet uptake remains challenge in LMICs.

Purpose of the study

This study aimed to explore the barriers to and facilitators of DSMP and preferences for intervention design and delivery in Bangladesh, an LMIC, with prevalent T2DM.

Methods

Sixteen qualitative focus group discussions (FGDs) with adults with T2DM and their caregivers were conducted in rural Bangladesh to explore preferences, barriers, and facilitators for community DSMP-related intervention programs. Data were thematically analyzed using a deductive theoretical domains framework (TDF) underpinned by the socio-ecological model.

Results

Overall, 117 participants (n = 58 with T2DM and n = 59 caregivers) were included in the analysis. Five overarching themes were identified, including (i) implementation of DSMP, (ii) community spirit and interconnectedness, (iii) environmental influences, (iv) healthcare professionals' role in DSMP, and (v) government support. Key barriers to DSMP identified for T2DM patients include knowledge implementation gaps, cultural practices, limited resources, and financial constraints. Facilitators include motivation, support from family and peers, and religious practices. Rural Bangladeshis prefer programs delivered at community clinics, viewing them as reliable, culturally appropriate central 'hubs' to assemble.

Conclusion

Barriers to and facilitators of DSMP were identified, and preferences for intervention design and delivery for implementing DSMP were explored. The findings provide a foundation for the critical need to implement programs that improve DSMP in Bangladesh, with the potential to translate to other LMIC settings.

"It just made sense to me!" A Qualitative Exploration of Individual Motivation for Time-Restricted Eating

Time-Restricted Eating (TRE), a form of intermittent fasting, has gained popularity for weight control and metabolic health. It is not incorporated into dietary and clinical guidelines, and hence is generally not being recommended to the public. This qualitative study explores how individuals have discovered TRE as a form of dietary practice and their motivations for practising it. Using purposive and snowball sampling, we recruited 21 participants who had engaged in TRE for at least 3 months (range 3 months to over 5 years). In-depth interviews were conducted with an interview guide developed based on the Health Belief Model. We utilised an inductive coding process and thematic analysis to identify the factors motivating TRE adoption. Seven main themes emerged: (1) dissatisfaction and resistance to prior or traditional approaches, (2) perceived broader health benefits, (3) principles of TRE deemed logical, (4) low to no cost of adoption, (5) manageable psychosocial barriers, (6) being non-restrictive and easy to use, and (7) compatibility with personal lifestyle. This study provided insights into early phase of TRE adoption among individuals in real world settings. Future research should explore health practitioners' perspectives on TRE to better understand the acceptability and potential use of TRE as a weight management approach.

Conquering diabetes by overcoming psychological barriers and embracing health

Living with chronic conditions like diabetes mellitus (DM) or insulin resistance (IR) requires significant self-management, adding to daily life stressors. This stress, known as diabetes distress, along with health empowerment from proper diet and lifestyle, and motivation to eat healthily, greatly impacts quality of life and disease outcomes. Different patient subgroups (type 1 diabetic (T1DM), type 2 diabetic (T2DM), and insulin resistant (IR) individuals) face these challenges differently. This research aims to compare people with IR and DM to those without, and to compare IR, T1DM and T2DM subgroups on psychological factors. Data was collected via an online questionnaire from 746 participants (average age 37.5 years). Among them, 405 had IR (N = 177) or DM (Type 1: N = 116; Type 2: N = 112), and 341 were controls. Results showed that T2DM individuals scored lower than controls on Identified Regulation, Interoceptive Awareness, and Search for Meaning in Life, while the IR group had higher body-mind disconnection. T1DM individuals experienced the highest emotional distress due to the disease but the lowest distress from regular check-ups compared to T2DM and IR groups. The gradient boosting classification model indicated that IR and T1DM groups are homogeneous, whereas T2DM is heterogeneous, with significant within-group variation in disease experience and management. Despite similarities in daily life challenges, significant differences exist in disease experience among the groups. Individual characteristics of T2DM individuals further diversify their attitudes towards disease management.

Common mistakes concerning diabetes management in daily clinical practice

Diabetes mellitus is a chronic metabolic disease, potentially leading to dire complications. Although there are numerous pharmaceutical treatments available, management of the disease is frequently not optimal. Managing diabetes in daily clinical practice can be challenging, and several common mistakes may occur. Healthcare providers must be aware of these errors to provide adequate patient care. In this review, some frequent mistakes in diabetes management are analyzed, focusing on factors such as medication management, blood glucose level monitoring, inadequate addressing of complications and comorbidities, lifestyle choices, patient education, and overall health counselling.

Patient-centered care model based on self-efficacy to improve self-care and quality of life of people with type 2 diabetes mellitus: A PLS-SEM approach

Background

The current model for managing type 2 diabetes mellitus (T2DM) is healthcare provider-centered rather than patient-centered. This approach may overlook individual patients' unique needs, potentially impacting the effectiveness of T2DM management goals.

Objective

This study aimed to develop a patient-centered care model based on self-efficacy to enhance self-care and improve the quality of life for individuals with T2DM.

Methods

The study employed a cross-sectional design with a sample size of 250 respondents recruited through multistage random sampling, Jember regency, East Java, Indonesia. The study variables included exogenous factors (people with T2DM, situational treatment, family, and healthcare services) and endogenous factors (self-efficacy, self-care, and quality of life). Data were collected from August to December 2022 using a questionnaire and analyzed descriptively and inferentially using SEM-PLS.

Results

The developed model was a good fit with strong predictive relevance (SRMR = 0.065; Q2 = 0.049). All exogenous factors-people with T2DM, situational treatment, family, and healthcare services-significantly affected self-efficacy (42.2%, 37%, 8.1%, and 17.3%; p <0.001). Self-efficacy had a 61.6% effect on self-care, and self-care had a 27.1% effect on quality of life (p <0.001). Only situational treatment factors had a direct effect on self-care (21.7%; p <0.001). All exogenous factors also influenced the quality of life through self-efficacy and self-care (7%, 6.2%, 1.3%, and 2.9%; p <0.05).

Conclusions

A patient-centered care model based on self-efficacy for managing T2DM can improve self-care behaviors and quality of life for individuals with T2DM. This model can be utilized by nurses in healthcare services to enhance the management of T2DM.

Patient motivation: A concept analysis

Background

Patient motivation is crucial in maintaining health-improving activities and helping patients recover from illnesses. Despite extensive research on patient motivation, this concept has not been clearly defined and remains ambiguous. The latest analysis of patient motivation was over two decades ago, thus necessitating the need to reexamine it in more updated literature.

Objective

This study aims to explore the concept of patient motivation.

Methods

The eight-step approach of Walker and Avant was used: concept selection, determining analysis aim, identifying concept use, defining attributes, model case identification, borderline and contrary case identification, antecedents and consequences identification, and empirical referent identification. Five databases, CINAHL, Cochrane, Medline, PubMed, ProQuest, and ScienceDirect, were searched for published works between 2014 and 2024 using the keywords "patient" and "motivation."

Results

The identified attributes of patient motivation are a psychological drive, a desire to adopt healthy behaviors, and goal-directed action. Antecedents of patient motivation are self-efficacy, provider-patient communication, and social support. Patient motivation leads to consequences, including healthier lifestyles and greater adherence and compliance.

Conclusion

The present concept analysis draws upon current literature to suggest the antecedents, attributes, and consequences of patient motivation. Nurses can promote healthier lifestyles and greater adherence and compliance among patients by employing techniques to raise self-efficacy and provide social support while enhancing patient-centered interactions.

Mindsets and self-efficacy beliefs among individuals with type 2 diabetes

Growth mindsets and self-efficacy beliefs have been known to predict and promote resilience, challenge seeking, and improved outcomes in areas such as education and intelligence. However, little is known about the role of these two potentially influential beliefs in the context of type 2 diabetes (T2D), specifically in terms of whether and in which domains (i.e., beliefs toward general life, general health, or condition-specific domains) these beliefs-or lack thereof-is prevalent among individuals with T2D. Given the lifelong challenges that individuals with diabetes often encounter with managing their disease, many may slip into a conceding negative belief that their diabetes is "too difficult to control" or simply "out of their hands," inhibiting proactive self-management efforts. Results from our study (n = 893) revealed that individuals with T2D had a significantly lower growth mindset towards their blood glucose level and lower self-efficacy towards their general health, blood glucose, and cholesterol levels compared to those without T2D. Among participants with T2D, further analyses showed a pattern of higher HbA1c among those with lower growth mindsets and self-efficacy toward their general health or blood glucose level. These findings identify the belief-domains that may pose barriers to necessary self-care behaviors, informing future interventions to promote improved diabetes care and management.

Are motivational and self-regulation factors associated with 12 months' weight regain prevention in the NoHoW study? An analysis of European adults

PURPOSE

Preventing weight regain can only be achieved by sustained changes in energy balance-related behaviors that are associated with weight, such as diet and physical activity. Changes in motivation and self-regulatory skills can support long-term behavioral changes in the context of weight loss maintenance. We propose that experiencing a supportive climate care is associated with enhanced satisfaction of basic psychological needs, intrinsic goals, and autonomous motivation. These factors are expected to be associate with the utilization of self-regulation skills, leading to more sustained behavior changes and ultimately preventing weight regain. This hypothesis was tested in this ancillary analysis of the NoHoW trial, where the study arms were pooled and followed for 12 months.

METHODS

The NoHoW was a three-center, large-scale weight regain prevention full factorial trial. In this longitudinal study, data were collected in adults who lost > 5% weight in the past year (N = 870, complete data only, 68.7% female, 44.10 ± 11.86 years, 84.47 ± 17.03 kg) during their participation in a 12-month digital behavior change intervention. Weight and validated measures of motivational- and self-regulatory skills-related variables were collected at baseline, six- and 12 months. Change variables were used in Mplus' path analytical models informed by NoHoW's logic model.

RESULTS

The bivariate correlations confirmed key mediators' potential effect on weight outcomes in the expected causal direction. The primary analysis showed that a quarter of the variance (r2 = 23.5%) of weight regain prevention was achieved via the mechanisms of action predicted in the logic model. Specifically, our results show that supportive climate care is associated with needs satisfaction and intrinsic goal content leading to better weight regain prevention via improvements in self-regulatory skills and exercise-controlled motivation. The secondary analysis showed that more mechanisms of action are significant in participants who regained or maintained their weight.

CONCLUSIONS

These results contribute to a better understanding of the mechanisms of action leading to behavior change in weight regain prevention. The most successful participants used only a few intrinsic motivation-related mechanisms of action, suggesting that habits may have been learned. While developing a digital behavior change intervention, researchers and practitioners should consider creating supportive climate care to improve needs satisfaction and intrinsic goal contents.

TRIAL REGISTRATION

ISRCTN, ISRCTN88405328 , registered 12/22/2016.

The Effects of Mindfulness on Glycemic Control in People with Diabetes: An Overview of Systematic Reviews and Meta-Analyses

Background: Previous research has demonstrated the effectiveness of mindfulness interventions in improving glycemic control. By enhancing attention control, emotion regulation, and self-awareness, mindfulness shows promise in managing the lifestyle factors associated with cardiovascular disease risk. However, the impact of mindfulness on glycemic control in people with diabetes remains unclear. This overview aims to summarize the current evidence of the impact of mindfulness interventions on glycemic control in people with diabetes and propose suggestions for future research. Methods: The author searched electronic databases (PubMed/MEDLINE, Embase, and Cochrane Library) to identify relevant systematic reviews and meta-analyses. The current evidence regarding the effects of mindfulness on glycemic control in people with diabetes was summarized. Results: This review evaluated a total of five systematic reviews and meta-analyses of randomized controlled trials (RCTs). Mindfulness interventions show potential for improving glycemic control as measured by hemoglobin A1c (HbA1c) levels, as well as reducing stress, depression, and anxiety in people with diabetes. Four out of five systematic reviews and meta-analyses reported a significant reduction in HbA1c levels by approximately 0.3%. However, the available studies lacked adequate description of key characteristics of study subjects, such as body mass index, medication, and disease conditions, which are essential for assessing the impact of mindfulness on glycemic control. Moreover, there was significant heterogeneity in the intervention methods employed across the included RCTs. Conclusions: Mindfulness interventions are effective in improving glycemic control in people with type 2 diabetes. However, the overall quality of the reviewed studies raises uncertainty regarding the effectiveness of mindfulness as a treatment for people with diabetes. Further research is necessary to elucidate the biological effects of mindfulness on physiological, neurological, and endocrinological functions in humans.

Continuous Glucose Monitoring and Physical Activity

Continuous glucose monitoring (CGM) use has several potential positive effects on diabetes management. These benefits are, e.g., increased time in range (TIR), optimized therapy, and developed documentation. Physical activity is a recommended intervention tool in diabetes management, especially for people with type 2 diabetes (T2D). The benefits of physical activity for people with diabetes can be seen as an improvement of glycemic control, glycemic variability, and the reduction of insulin resistance. In relation to the physical activity of people with T2D, the benefits of CGM use can even be increased, and CGM can be a helpful tool to prevent adverse events due to physical activity of people with diabetes, such as hypoglycemic events and nocturnal hypoglycemia after sports. This narrative review aims to provide solid recommendations for the use of CGM in everyday life physical activities based on the noted benefits and to give a general overview of the guidelines on physical activity and CGM use for people with diabetes.

Discovering Engagement Personas in a Digital Diabetes Prevention Program

Digital health technologies are shaping the future of preventive health care. We present a quantitative approach for discovering and characterizing engagement personas: longitudinal engagement patterns in a fully digital diabetes prevention program. We used a two-step approach to discovering engagement personas among n = 1613 users: (1) A univariate clustering method using two unsupervised k-means clustering algorithms on app- and program-feature use separately and (2) A bivariate clustering method that involved comparing cluster labels for each member across app- and program-feature univariate clusters. The univariate analyses revealed five app-feature clusters and four program-feature clusters. The bivariate analysis revealed five unique combinations of these clusters, called engagement personas, which represented 76% of users. These engagement personas differed in both member demographics and weight loss. Exploring engagement personas is beneficial to inform strategies for personalizing the program experience and optimizing engagement in a variety of digital health interventions.

Effect of self-managed lifestyle treatment on glycemic control in patients with type 2 diabetes

The lack of effective, scalable solutions for lifestyle treatment is a global clinical problem, causing severe morbidity and mortality. We developed a method for lifestyle treatment that promotes self-reflection and iterative behavioral change, provided as a digital tool, and evaluated its effect in 370 patients with type 2 diabetes (ClinicalTrials.gov identifier: NCT04691973). Users of the tool had reduced blood glucose, both compared with randomized and matched controls (involving 158 and 204 users, respectively), as well as improved systolic blood pressure, body weight and insulin resistance. The improvement was sustained during the entire follow-up (average 730 days). A pathophysiological subgroup of obese insulin-resistant individuals had a pronounced glycemic response, enabling identification of those who would benefit in particular from lifestyle treatment. Natural language processing showed that the metabolic improvement was coupled with the self-reflective element of the tool. The treatment is cost-saving because of improved risk factor control for cardiovascular complications. The findings open an avenue for self-managed lifestyle treatment with long-term metabolic efficacy that is cost-saving and can reach large numbers of people.

Treatment self-regulation questionnaire across three self-care behaviours: An instrument validation study in Iranian patients with type 2 diabetes mellitus

Aim

The study aimed at testing the validity and reliability of the Persian version of the treatment self‐regulation questionnaire (TSRQ‐15) across healthy diet, exercise and medication‐use/glucose‐monitoring among Iranian people with type‐2 diabetes.

Design

Cross‐sectional design.

Methods

Content validity was investigated by 16 experts. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were employed. Construct validity, convergent/discriminant validity and internal consistency were examined. Concurrent validity was assessed using Spearman's rho correlation across different behaviours.

Results

Content validity was confirmed for Persian TSRQ‐15. A three‐factor structure was revealed, in which external regulation and introjected regulations were validated, while amotivation and autonomous failed to show discriminant validity. Internal consistency was sound, and concurrent validity was approved. The Persian version of TSRQ‐15 was shown to be a valid and reliable tool for assessing motivation behind the practice of healthy diet, exercise and medication‐use/glucose‐monitoring in people with type 2 diabetes.

Motivation for Treatment Correlating Most Strongly with an Increase in Satisfaction with Type 2 Diabetes Treatment

INTRODUCTION

We previously reported several factors that cross-sectionally correlate with treatment satisfaction in Japanese patients with type 2 diabetes visiting diabetes clinics. The aim of this study is to identify factors associated with longitudinal changes in treatment satisfaction in patients with type 2 diabetes.

METHODS

The study included 649 patients with type 2 diabetes treated with oral glucose-lowering agents who completed the first questionnaire in 2016. The collected data included scores from the Diabetes Treatment Satisfaction Questionnaire (DTSQ) and other parameters regarding diabetes treatment. We analyzed 1-year longitudinal changes in DTSQ scores and investigated factors associated with these changes.

RESULTS

Univariate linear regression analyses showed that changes in body weight, adherence to diet therapy, adherence to exercise therapy, cost burden, motivation for treatment, regularity of mealtimes, and perceived hypoglycemia correlated with changes in DTSQ scores. On the basis of multiple linear regression analyses, a decrease in hypoglycemia (β ± SE = - 0.394 ± 0.134, p = 0.0034), cost burden (β ± SE = - 0.934 ± 0.389, p = 0.017), and an increase in treatment motivation (β ± SE = 1.621 ± 0.606, p = 0.0077) correlated with DTSQ score increases, suggesting that motivation for treatment had the strongest impact on score increases. Subgroup analyses revealed that an increase in motivation for treatment most significantly correlated with a DTSQ score increase in obese and poor glycemic control groups, regardless of age.

CONCLUSION

This is the first longitudinal study clarifying that an increase in motivation for treatment most strongly correlates with an increase in DTSQ score in patients with type 2 diabetes.

Effect of Digital Lifestyle Management on Metabolic Control and Quality of Life in Patients with Well-Controlled Type 2 Diabetes

INTRODUCTION

The lack of effective, scalable solutions for lifestyle treatment is a global clinical problem, causing severe morbidity and mortality. Digital tools could enable broad utility, but long-term metabolic outcomes and the influence on quality of life are unclear.

METHODS

We developed a new method for lifestyle treatment that promotes self-reflection and iterative behavioural change, provided as a digital tool, and evaluated its effect on glycaemic control in patients with type 2 diabetes with HbA1c below 52 mmol/mol (n = 297). As a secondary analysis, its effect on quality of life (using SF-12) was examined in both participants with and without diabetes (total n = 1914). The tool was evaluated during a 12-week randomization period to assess the existence of effect, with a subsequent open-label follow-up to study long-term outcomes.

RESULTS

Participants were randomized to wait or access the intervention tool. The mean difference in HbA1c was 2 mmol/mol (95% CI - 4 to 0; P = 0.02) after 12 weeks in participants with type 2 diabetes. The groups were then merged to enable all participants to use the tool. The mean HbA1c reduction from baseline in patients with type 2 diabetes using the tool was 2 mmol/mol compared with matched controls (95% CI - 3 to 0; P = 0.005). In users with HbA1c above 45 mmol/mol, the mean difference between the groups was 4 mmol/mol (95% CI - 7 to - 2). The improvements were sustained during the follow-up of 1 year on average. Users of the tool also had improved quality of life from baseline to 6 months, mainly observed in non-diabetic participants.

CONCLUSION

The tool does not require in-person reinforcement or increased healthcare resources, and the marginal cost is fundamentally lower than pharmacological treatment and most existing lifestyle interventions. The results therefore open a new means for self-managed lifestyle treatment with long-term metabolic efficacy that can benefit large numbers of people.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04624321 and NCT05006508.

Factors Related to Diabetes Self-Management Among Patients with Type 2 Diabetes: A Chinese Cross-Sectional Survey Based on Self-Determination Theory and Social Support Theory

PURPOSE

Self-management behavior (SMB) plays a significant role in glycemic control. This study aimed to explore the factors related to SMB among patients with type 2 diabetes and how these factors interacted with each other.

PATIENTS AND METHODS

Patients diagnosed with type 2 diabetes were recruited from 18 community healthcare stations (CHSs) from six community healthcare centers (CHCs) in Beijing, China from April to May in 2017. Motivation, competence, autonomy support, social support, self-management skills, adherence to self-monitoring of blood glucose (SMBG) and haemoglobin A1c (HbA1c) measurement were tested by questionnaire. Correlation analysis and path analysis were performed so as to identify the factors associated with patients' SMB.

RESULTS

A total of 532 participants completed this study. Participants who have good compliance to SMBG got higher scores in social support (F = 7.68, p = 0.01), competence (F = 10.47, p = 0.01), and skills (F = 12.34, p < 0.01). Higher competence (β = 0.03, P < 0.001), higher social support (β = 0.01, P < 0.001), better skills(β = 0.01, P < 0.001) directly led to better adherence to SMBG. Social support had a positive effect on autonomy support (β = 0.69, P < 0.001), motivation (β = 0.45, P < 0.001), competence (β = 0.28, P < 0.001), skills (β = 0.14, P < 0.001), which was also indirectly linked to better adherence to SMBG. Better self-management skills directly led to better adherence to HbA1c measurement (β = 0.03, P < 0.001). Social support had a positive effect on autonomy support (β = 0.69, P < 0.001), motivation (β = 0.45, P < 0.001), competence (β = 0.28, P < 0.001), skills (β = 0.14, P < 0.001), which was also indirectly linked to better adherence to HbA1c measurement.

CONCLUSION

Self-determination theory and social support theory were practical in explaining SMB in Chinese population. Competence, motivation and social support played an important role in diabetic self-management. Paying attention to the promotion of individual's intrinsic motivation and self-efficacy may be able to help patients maintain self-management behavior in the long-term routine.

Barriers to and facilitators of diabetes self-management practices in Rupandehi, Nepal- multiple stakeholders' perspective

BACKGROUND

Self-management of diabetes is associated with glycaemic control and adherence to medication and healthy lifestyle practices. There is lack of information on the barriers to and facilitators of diabetes self-management practices in low income country, Nepal. This study aimed to explore the barriers to and facilitators of Type 2 diabetes self-management practices taking multiple stakeholders' perspectives in Nepal.

METHODS

Four focus group discussions and 16 semi-structured interviews with people with Type 2 diabetes, caregivers, health care providers and health managers were conducted from April to May 2018 in Rupandehi district of Western Nepal. They were audio-recorded, transcribed, and analysed using a thematic approach.

RESULTS

Five main themes emerged that influenced diabetes self-management practices: individual factors, socio-cultural and economic factors, health system and policy factors, availability and accessibility of resources, and environmental factors. The important barriers were: lack of knowledge about diabetes self-management practices, cultural practices, insufficient counselling, lack of guidelines and protocols for counselling, and financial problems. The major facilitators were: motivation; support from family, peers, and doctors; and availability of resources in the community.

CONCLUSION

Based on our findings, a multilevel approach is needed to address these barriers and facilitators. These findings will help guide strategies to develop programs that impart knowledge and skills to improve the diabetes self-management practices of people with Type 2 diabetes.