Contrasting patient and practitioner perspectives in type 2 diabetes management

"I'm Worth Saving": Making Sense of Medication Taking in a Care Coordination Organization

Patients and healthcare providers (HCPs) may communicatively make sense of medication taking in divergent ways. Often, HCPs prioritize medication adherence, the extent to which patients consume medications as prescribed. In contrast, patients may focus on how medications fit in with their everyday lives. Care coordination organizations (CCOs) provide cohesive, interdisciplinary, health services to chronically ill patients and may help bridge the gap between patient and HCP sensemaking. Our qualitative study asked: How do patients and HCPs involved in a CCO communicatively make sense of medication taking? Through thematic analysis, we found three themes related to patients' sensemaking. Patients (N = 9) made sense of medication taking (1) as necessary and important through embodied experiences, social discourses, and interpersonal interactions; (2) as easy when supported; and (3) through building bonds. We also found three themes related to HCPs' sensemaking: HCP participants (N = 5) made sense of medication taking (1) through dialogue with patients; (2) by interacting in patients' home spaces; and (3) through building relationships with patients. Our final theme explores how communicative sensemaking became more complicated for participants in the context of psychotropic medications. Using Mishler's Voice of the Lifeworld (VoL) and Weick's sensemaking, we advance a constitutive perspective on medication taking. We suggest that researchers and HCPs should focus on constructing shared meanings about medication taking through dialogue, rather than on increasing adherence. Our study provides evidence that, by promoting engagement with the VoL, CCOs may facilitate such dialogs.

A Formative Assessment of Social Determinants of Health Related to Early Childhood Caries in Two American Indian Communities

In the United States, children from diverse ethnic groups and those with low socioeconomic status are at a significantly increased risk for early childhood caries. Despite the efforts focused on decreasing early childhood caries in American Indian (AI) populations, these children have the highest incidence of dental caries of any ethnic group, with four times the cases of untreated dental caries compared to white children. This qualitative formative assessment was conducted in two AI communities. Semi-structured interviews (n = 57) were conducted with caregivers and providers to understand the social and community contexts in which oral health behaviors and practices occur from the perspective of the caregivers, oral health care providers, and social service providers in the communities. The analysis was informed by the social determinants of health framework. The key social determinants of pediatric oral health relevant to our study communities included limited access to: oral health promoting nutritious foods, transportation for oral health appointments, and pediatric specialty care. This formative assessment provided locally and contextually relevant information to shape the development of an oral health clinical trial intervention to address early childhood caries in these two communities.

Assessing the Clinical Utility of Point of Care HbA1c in the Ophthalmology Outpatient Setting

Background/Aims

Effective management of diabetic retinopathy requires multidisciplinary input. We aimed to evaluate the impact of point of care (POC) HbA1c testing as a tool to identify patients most in need of specialist diabetologist input and assess the accuracy and determinants of patients’ insight into their glycaemic and blood pressure control.

Methods

Forty-nine patients with diabetic retinopathy were recruited from the eye clinic at Great Western Hospital. Patients completed a questionnaire and POC HbA1c and blood pressure values were measured. Statistical analysis was completed with SPSS v23.

Results

Mean age was 64.4 years, median interval since the last formal HbA1c reading was 10.2 months and the mean POC HbA1c was 64.1 mmol/mol. HbA1c significantly correlated with the degree of retinopathy. Of the patients, 81.6% had POC readings above the levels recommended by the National Institute for Health and Care Excellence, with only 16.3% having insight into this. Insight to HbA1c levels was predicted by age but not by duration of disease. Fourteen patients (33.3%) identified with high HbA1c readings were referred to secondary diabetic services and 88.8% of patients felt that the test was useful and likely to improve their diabetic control.

Conclusion

The majority of patients had poor insight into their diabetes control, with sub-optimal treatment and follow-up. Poor insight is high in younger patients, suggesting that POC HbA1c testing is particularly important in educating younger patients who may be Type 1 diabetics with more severe disease. POC HbA1c represents a cost-effective, reproducible and clinically significant tool for the management of diabetes in an outpatient ophthalmology setting, allowing the rapid recognition of high-risk patients and appropriate referral to secondary diabetic services.

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Patient-Centered Self-Management in Patients with Chronic Kidney Disease: Challenges and Implications

This review aims to identify attributes of patient-centered self-management (PCSM) in the current literature and explore its implementation in resolving patient obstacles in chronic kidney disease (CKD) treatment and management. A search of relevant articles and literature on PCSM, integrated care, and challenges of CKD management was conducted. Vital attributes of PCSM and current self-management interventions employed to resolve patient obstacles in CKD management were identified from inclusion studies. Findings affirm that PCSM strategies have positive effects on CKD management, but a lack of quality primary study, and long-term evidence presents the need for further development. Future research should focus on the development of a standardized and universal integrated PCSM model and a uniform system of data collection in the clinical setting. The difficulty of CKD management lies in how it is a comorbid and progressive disease. A pure biomedical approach is inadequate. Our review recommends that an integrated PCSM approach with health literacy and information technology intervention, which unifies and integrates patient education, can address the difficulties that are contributing to unsuccessful treatment outcomes. An integrated PCSM model should be implemented systematically and methodologically into future CKD management and health policies.

"I had no other choice but to catch it too": the roles of family history and experiences with diabetes in illness representations

BACKGROUND

A family history of diabetes and family members' experiences with diabetes may influence individuals' beliefs and expectations about their own diabetes. No qualitative studies have explored the relationship between family history and experiences and individuals' diabetes illness representations.

METHODS

Secondary data analysis of 89 exploratory, semi-structured interviews with adults with type 1 or type 2 diabetes seeking care in an urban health system. Participants had a recent diabetes-related ED visit/hospitalization or hemoglobin A1c > 7.5%. Interviews were conducted until thematic saturation was achieved. Demographic data were collected via self-report and electronic medical record review. Interviews were audio-recorded, transcribed, and coded using a conventional content analysis approach. References to family history and family members' experiences with diabetes were analyzed using selected domains of Leventhal's Common Sense Model of Self-Regulation.

RESULTS

Participants cited both genetic and behavioral family history as a major cause of their diabetes. Stories of relatives' diabetes complications and death figured prominently in their discussion of consequences; however, participants felt controllability over diabetes through diet, physical activity, and other self-care behaviors.

CONCLUSIONS

Findings supported an important role of family diabetes history and experience in development of diabetes illness representations. Further research is needed to expand our understanding of the relationships between these perceptions, self-management behaviors, and outcomes. Family practice providers, diabetes educators and other team members should consider expanding assessment of current family structure and support to also include an exploration of family history with diabetes, including which family members had diabetes, their self-care behaviors, and their outcomes, and how this history fits into the patient's illness representations.

Primary care physician perspectives on barriers and facilitators to self-management of type 2 diabetes

Objectives

To assess physician perspectives on perceived barriers and facilitators to type 2 diabetes self-management (DSM) in a primary care setting.

Methods

The study utilized survey methodology to measure perspectives of primary care physicians on DSM and the challenges they face in managing patients with poor glycaemic stability. Demographic and practice site-related information of the physicians were also collected.

Key findings

Of the 21 physicians who responded (53.8% response rate), 71.2% were aged 50 years or older, 54.2% had ≥25 years of clinical experience, and 50% practiced in an urban setting. The physicians examined 5–60 patients with type 2 diabetes per week (mean = 20), and over 75% of them spent <20 min on face-to-face visits. Approximately, 95% of physicians considered self-care activities such as regular moderate exercise, following a recommended diet, regular blood glucose testing, proper insulin administration and adherence to oral medication as extremely important. Practice-related aspects such as patient–physician communication, patient health literacy and patient follow-up were unanimously considered extremely important, and performance on these measures was rated positively. Interestingly, 66% of physicians felt responsible to some extent for their patient's failure to reach type 2 DSM goals. Physician perceived barriers that contributed to clinical inertia included cost of medications, lack of patient motivation and knowledge, non-compliance with diet and medications, polypharmacy and lack of time and social support.

Conclusions

The study results underscore the importance of DSM in the overall management of type 2 diabetes. Addressing the challenges faced by physicians may result in better self-management and improved clinical outcomes in type 2 diabetes population.

Ascribed Meaning of Disease Control: Perspectives of Patients With Type 2 Diabetes

Background

Contemporary treatment of type 2 diabetes mellitus (hereafter diabetes) heavily emphasizes "diabetes control," largely defined by measurable blood glucose parameters. Little is known about how people living with the condition themselves define diabetes control within the lived experience of their disease.

Methods

As part of a qualitative study investigating the subjective construction of diabetes, 83 in-depth interviews were conducted with African American and non-Hispanic white older adults. Using content analysis, 4237 pages of narrative data were analyzed to explore how informants conceptualized diabetes control.

Findings

Four themes emerged from the data, describing varied understandings of diabetes control: (a) blood sugar regulation, (b) practicable treatment adherence, (c) bodily experience, and (d) degree of pharmaceutical need. Findings demonstrate that among persons with diabetes, the term diabetes control is multifaceted.

Conclusion

While clinical guidelines have established target blood glucose parameters as the standard indicator of diabetes control, persons with diabetes conveyed varied and diverse meanings situated within personal experiences. To foster empathetic and collaborative care, health-care providers tending to this population may consider integrating the emergent themes into communicative and treatment approaches.

Perceptions of diabetes control among people with type 2 diabetes treated with basal insulin in Sweden, Switzerland, and the United Kingdom

OBJECTIVE

To investigate perceptions of control among people with uncontrolled and well controlled type 2 diabetes (T2D) treated with basal insulin, as well as differences in perceptions and diabetes management practices between the two groups.

RESEARCH DESIGN AND METHODS

Web surveys of 1012 people with uncontrolled T2D (HbA_1c >8.0% or 64 mmol/mol) on basal insulin in Sweden, Switzerland, and the UK and 295 people with well controlled T2D (HbA_1c <7.5% or 58 mmol/mol) on basal insulin in the UK were conducted.

RESULTS

People with uncontrolled T2D perceived a wide range of factors as very/extremely important for deciding whether they are well controlled, including diet (80.7%), HbA_1c value (78.9%), times per day insulin taken (78.8%), insulin units taken per day (77.6%), and energy levels (74.5%). Fifty-one percent of uncontrolled respondents considered the past week or more recently when thinking about control. Perceived major obstacles to control included stress (75.4%), other health issues (70.8%), medicine side effects (69.9%), food cravings (69.8%), doctor not understanding individual situation (67.6%), and life crises (66.9%). Many uncontrolled respondents reported that diabetes was very/extremely interfering with their lives, including energy level (71.0%), performance at work (70.0%), general health (69.9%), and doing what one wants (69.3%). Analyses showed significant differences between well controlled and uncontrolled UK respondents. Compared to the uncontrolled, people with well controlled T2D were significantly more likely to consider the last 24 hours/current time when thinking about control (50% vs. 21%, p < 0.001) and reported greater healthcare contact related to diabetes and more frequent glucose measurement. Study limits include potential selection bias of web surveys and possible recall bias in patient-reported data.

CONCLUSIONS

The results illuminate how people with T2D treated with basal insulin perceive control and show important differences between the well controlled and uncontrolled. Findings may have implications for improving patient and physician education and diabetes management.

A Nurse-Coaching Intervention for Women With Type 2 Diabetes

PURPOSE

The purpose of this pilot study was to determine the efficacy of a 6-month nurse-coaching intervention that was provided after diabetes education for women with type 2 diabetes.

METHODS

In this pilot study, 53 women were randomized to the nurse-coaching intervention or a standard care control condition. The nurse-coaching intervention consisted of 5 individualized sessions and 2 follow-up phone calls over 6 months. The nurse-coaching sessions included educational, behavioral, and affective strategies. Data were collected on physiologic adaptation (hemoglobin A1c [A1C] and body mass index [BMI]), self-management (dietary and exercise), psychosocial adaptation (diabetes-related distress and integration), and treatment satisfaction at baseline, 3 months, and 6 months.

RESULTS

Women in the treatment group demonstrated better diet self-management, less diabetes-related distress, better integration, and more satisfaction with care, and had trends of better exercise self-management and BMI. The A1C levels improved in both groups at 3 months, yet the difference between the groups was not significant. Attendance at nurse-coaching sessions was 96%.

CONCLUSIONS

This nurse-coaching intervention demonstrates promise as a means of improving self-management and psychosocial outcomes in women with type 2 diabetes.

Prediction of self-care behaviour on the basis of knowledge about chronic kidney disease using self-efficacy as a mediator

AIMS AND OBJECTIVES

This study was to investigate: (1) the important factors in the self-care of chronic kidney disease (CKD) patients and (2) the mediating effects of self-efficacy on knowledge and self-care.

BACKGROUND

Chronic kidney disease has become a major global health issue and is one of the top 10 leading causes of death in Taiwan where the dialysis population ranks first in the world. The number of patients with poor self-care behaviours continues to rise despite ongoing health education. Knowledge and self-efficacy are important factors that influence self-care behaviour; however, very few articles have examined the relationships among them.

DESIGN

Cross-sectional and correlational design.

METHODS

Subject recruitment was conducted by purposive sampling in the renal outpatient clinics and dialysis centres of two teaching hospitals in northern Taiwan. A total of 247 patients with chronic kidney disease (stages 1-5) were enrolled.

RESULTS

(1) Knowledge was positively correlated with self-efficacy (r = 0·41, p < 0·01) and with self-care (r = 0·18, p < 0·01). Self-efficacy (r = 0·44, p < 0·01) as well as age (r = 0·15, p < 0·01) were positively correlated with self-care. (2) The relationship between knowledge and self-care was fully mediated by self-efficacy (z = 4·82, p < 0·001) and the effect was 50%.

CONCLUSION

The results showed that self-efficacy was a crucial mediator between knowledge and self-care. In addition to providing knowledge to chronic kidney disease patients, healthcare professionals should also offer strategies that can enhance self-efficacy to increase self-care behaviours in chronic kidney disease patients and implement effective disease management.

RELEVANCE TO CLINICAL PRACTICE

Incorporate self-efficacy strategies into the process of health education to improve knowledge and the effectiveness of self-care. The findings of this study provide evidence of effectiveness of the use of group activity through self-management and self-efficacy enhancement programmes and may influence the policy makers to consider adding or modifying the reimbursement criteria.

Perceptions of diabetes control among physicians and people with type 2 diabetes uncontrolled on basal insulin in Sweden, Switzerland, and the United Kingdom

Objective A large proportion of people with type 2 diabetes (T2D) remain uncontrolled on basal insulin. Yet, there is limited understanding of how people with uncontrolled type 2 diabetes (PWUD) perceive control and insulin intensification and whether their perceptions differ from those of physicians. The purpose of the study was to investigate perceptions of control and views on insulin intensification among physicians and PWUD. Research design and methods Web surveys of 1012 PWUD on basal insulin and 300 physicians were conducted in Sweden, Switzerland, and the United Kingdom. Results Analyses revealed significant differences between physicians and PWUD. Physicians were significantly more likely than PWUD to indicate that HbA1c (85.0% vs. 78.9%, p < 0.05), complications from diabetes (89.3% vs. 75.3%, p < 0.001), and frequency/severity of hypoglycemia (93.3% vs. 68.6%, p < 0.001) were very/extremely important for deciding whether or not diabetes is well controlled. In contrast PWUD were significantly more likely to place importance on a variety of factors, including energy levels (74.5% vs. 33.0%, p < 0.001), insulin units/day (77.6% vs. 29.0%, p < 0.001) and how predictable life is (72.1% vs. 29.3%, p < 0.001). PWUD also perceived significantly greater obstacles to control and viewed uncontrolled T2D as more interfering in their lives compared to physicians. Physicians were most reluctant to intensify insulin when there is a lack of patient agreement. Worries about weight gain and feelings of 'getting sicker' were the most frequently reported reasons why PWUD on basal insulin were reluctant to intensify insulin. Conclusions Results revealed a significant disconnect between physicians and PWUD in their perceptions of diabetes control. While physicians generally expressed a more focused and clinical view of diabetes control, patients had a broader view. Results also provide insights into PWUD and physicians' reluctance to intensify insulin. The findings suggest that physician and patient education on differing perceptions could benefit communication and improve diabetes management.

Group affiliation in self-management: support or threat to identity?

BACKGROUND

Self-management is considered important in chronic illness, and contemporary health policy recommends participation in support groups for individuals with chronic conditions. Although withdrawal from or non-participation in support groups is an important problem, there is limited knowledge about individuals' own motivation for participation in or withdrawal from self-management support groups.

OBJECTIVES

To investigate how individuals with type 2 diabetes perceive participation in group-based self-management support.

DESIGN

This is a qualitative focus group study using a semi-structured interview guide.

SETTING AND PARTICIPANTS

Sixteen participants diagnosed with type 2 diabetes were included in the study. Individuals with and without group affiliations were mixed in three focus groups to trigger discussions. In the analysis, reoccurring themes of engagement and discussions between participants were focused within a theoretical frame of institutional logic. The focus groups are seen as social spaces where participants construct identity.

RESULTS

Both participation and non-participation in group-based self-management support are associated with dealing with the stigma of having type 2 diabetes. Negotiations contribute to constructing an illness dignity as a response to the logic of moral responsibility for the disease.

DISCUSSION AND CONCLUSION

Contemporary policy contributes to societal understandings of individuals with type 2 diabetes as morally inadequate. Our study shows that group-based self-management support may counteract blame and contribute in negotiations of identity for individuals with type 2 diabetes. This mechanism makes participation in groups beneficial for some but stigma inducing for others.

Diabetes Causation Beliefs Among Spanish-Speaking Patients

PURPOSE

The purpose of this study was to explore how the inquiry of cultural diabetes causation beliefs can improve Hispanic/Latino patient self-management.

METHODS

Two semistructured focus groups were conducted with 13 Hispanic/Latinos adults diagnosed with type 2 diabetes mellitus. Prior to taking part in the group discussion, participants completed a demographic survey and the Illness Perception Questionnaire-Revised.

RESULTS

The top 5 diabetes causation items endorsed by participants per the questionnaire included stress or worry, behavior, hereditary, diet/eating habits, and family problems/worries. The qualitative analysis revealed stress as a recurring theme for a cause of diabetes. Work stress was specifically identified as a contributor to unhealthy eating and diabetes. Most participants were aware of and believed in susto and referred to it as coraje (anger). Participants believed that asking patients about their diabetes causation beliefs and emotional status can help health professionals (1) better understand the patient and (2) identify and prioritize diabetes treatments. Participants also indicated that the role of doctors is important and the encouragement that they give to patients is clinically and spiritually valued.

CONCLUSIONS

Stress was identified as a cause of diabetes in addition to unhealthy diets and heredity. Asking patients about diabetes causation beliefs and emotional status may help prioritize treatment and management goals.

A systematic review of research into black and ethnic minority patients' views on self-management of type 2 diabetes

CONTEXT

Eliciting patients' views of type 2 diabetes self-management provides insights on how policy and services might better support the needs of this population.

OBJECTIVE

To synthesize black and ethnic minority patients' views on the barriers and facilitators influencing the self-management of type 2 diabetes.

SEARCH STRATEGY

A systematic search of international literature published in nine electronic databases was undertaken in 2008. Search strategies used both MeSH and free-text terms. Two relevant journals were also hand searched.

INCLUSION CRITERIA

Any primary empirical study published in the English language since 1986 that reported black and ethnic minority patients' views on type 2 diabetes self-management.

DATA EXTRACTION AND SYNTHESIS

Data were extracted and study quality was formally assessed. Data were analysed using thematic synthesis.

MAIN RESULTS

Fifty-seven studies were included, of qualitative (n = 54), mixed-method (n = 2) or quantitative (n = 1) design. Studies were from North America (n = 41), Europe (n = 14) and Australia (n = 2), including 1735 participants in total. Three analytical themes emerged: 'Importance of identity'; 'Being understood by others' and 'Making sense of condition', all linked conceptually under the overarching theme 'Sense of self'. The quality of the studies varied.

DISCUSSION AND CONCLUSIONS

The findings provide insight into what black and minority ethnic people regard as the barriers to, and facilitators of self-management, as opposed to what health professionals, policy makers and trial researchers may have assumed. Recognition of the views of people with diabetes is essential for the design and delivery of patient-centred care and policies.

Self-Management and Self-Management Support Outcomes: A Systematic Review and Mixed Research Synthesis of Stakeholder Views

INTRODUCTION

Self-management has received growing attention as an effective approach for long-term condition management. Little is known about which outcomes of supported self-management are valued by patients, their families, health professionals and those who commission self-management services. This study systematically reviewed published empirical evidence in accordance with PRISMA guidelines to determine the outcomes of self-management valued by these key stakeholder groups, using three prominent exemplar conditions: colorectal cancer, diabetes and stroke.

AIM

To systematically review the literature to identify which generic outcomes of self-management have been targeted and are considered important using three exemplar conditions (colorectal cancer, diabetes and stroke), which collectively have a range of features that are likely to be representative of generic self-management issues.

METHODS

Systematic searching of nine electronic databases was conducted in addition to hand searches of review articles. Abstracts were identified against inclusion criteria and appraised independently by two reviewers, using a critical appraisal tool. Synthesis of findings was conducted using mixed research synthesis.

RESULTS

Over 20,536 abstracts were screened. 41 studies which met the review criteria were fully retrieved and appraised. The majority of evidence related to diabetes. Few studies directly focussed on stakeholders' views concerning desired self-management outcomes; the majority of evidence was derived from studies focusing upon the experience of self-management. The views of health care commissioners were absent from the literature. We identified that self-management outcomes embrace a range of indicators, from knowledge, skills, and bio-psychosocial markers of health through to positive social networks.

CONCLUSIONS

Patients', families', health professionals' and commissioners' views regarding which outcomes of self-management are important have not been clearly elicited. The extent to which bio-psychosocial indicators relate to successful self-management from the perspectives of all groups of stakeholders is unknown. Further investigation regarding which self-management outcomes are considered important by all stakeholders is necessary to guide the commissioning and design of future self-management services.

Who is in control? Clinicians' view on their role in self-management approaches: a qualitative metasynthesis

OBJECTIVE

To explore clinician perceptions of involvement in delivery of self-management approaches.

SETTING

All healthcare settings.

DESIGN

EBSCO, Scopus and AMED databases were searched, in July 2013, for peer-reviewed studies in English reporting original qualitative data concerning perceptions of clinicians regarding their involvement in or integration of a self-management approach. Of 1930 studies identified, 1889 did not meet the inclusion criteria. Full text of 41 studies were reviewed by two independent reviewers; 14 papers were included for metasynthesis. Findings and discussion sections were imported into Nvivo-10 and coded line-by-line. Codes were organised into descriptive themes and cross-checked against original sources to check interpretation, and refined iteratively until findings represented an agreed understanding. Studies were appraised for quality.

RESULTS

Delivering self-management in practice appeared to be a complex process for many clinicians. The issue of 'control' arose in all studies, both in the qualitative data and authors' interpretations. The first theme: Who is in control?--represented ways clinicians talked of exercising control over patients and the control they expected patients to have over their condition. The second theme: Changing clinician views--reflected what appeared to be an essential transformation of practice experienced by some clinicians in the process of integrating self-management approaches into the practice. A range of challenges associated with shifting towards a self-management approach were reflected in the third theme, Overcoming challenges to change. Tensions appeared to exist around forming partnerships with patients. Strategies found helpful in the process of change included: dedicating time to practice reciprocity in communication style, peer support and self-reflection.

CONCLUSIONS

A consistent finding across studies is that 'control' is a key feature of how self-management is viewed by clinicians. They described challenges associated with the paradigm shift required to share or let go of control. Future research should identify whether strategies described by clinicians are key to successful self-management.

Listening to Older Adults' Values and Preferences for Type 2 Diabetes Care: A Qualitative Study

Individuals' values and preferences have a considerable impact on their motivation and, therefore, their willingness to follow treatment recommendations. This qualitative study aimed to describe older adults' values and preferences for type 2 diabetes care. Older adults valued an effective physician-patient treatment relationship and quality of life in their diabetes care. They preferred physicians who knew them as a person and were honest about their diabetes treatment and progression of the illness. When developing treatment plans, providers should assess the effect that treatment will likely have on older adults' health, while explicitly acknowledging their values and preferences for care as a prelude to better patient-centered care and potentially shared decision-making.

Differences in the perceptions of self-care, health education barriers and educational needs between diabetes patients and nurses

Abstract This study examined the differing perceptions of diabetic patients and their nurses regarding the completion of self-care activities, barriers to participation in diabetes health education, and diabetic patients' educational needs to promote better health care for patients with diabetes in Taiwan. This study employed a cross-sectional survey. The data were collected during 2009. Questionnaires were developed to collect data on a convenience sample of 312 patients with type 2 diabetes and 202 nurses recruited from diabetes clinics in Taiwan. Perceptions of self-care behavior were statistically significantly different between patients and nurses (t=-5.05, P<0.000). The patients perceived themselves to be more successful at completing self-care tasks whereas nurses perceived patients to be less successful at completing self-care tasks. Nurses perceived patients to experience greater difficulties in diabetes health education (t=18.36, P<0.000). Nurses perceived there to be a greater need for health education as compared with patients (t=9.03, P<0.000).

Do patients and physicians agree on diabetes management? A study conducted in public healthcare centres in Brazil

OBJECTIVE

To explore to what extent patients with diabetes agree with their physicians on diabetes management and whether the agreement varies according to patients' socio-demographic characteristics.

METHODS

A cross-sectional study was conducted among patients with diabetes and their Family Health physicians in 108 healthcare centres in Belo Horizonte, Brazil. Patients and physicians were interviewed face-to-face using standard questionnaires. Physicians were unaware of which of their patients would be interviewed. Their responses were compared using descriptive statistics and Cohen's weighted kappa.

RESULTS

282 patient-physician pairs were included. Kappa coefficients were often low, the highest was found for presence of diabetic foot and the lowest for kidney disease. Physicians tended to overestimate patients' risk of diabetes complications and underestimate patients' adherence to all diabetes self-management activities as well as diabetes control. Moreover, the agreement rate regarding adherence to diet, foot care and medicine prescriptions was significantly higher among male, younger and higher educated patients.

CONCLUSION

Results indicate that physicians' recommendations are generally poorly apprehended by their patients, especially by the lower educated, compromising the goal of patient-centred care.

PRACTICE IMPLICATIONS

Educational programmes need to incorporate strategies to improve the comprehension and effectiveness of physician-patient communication, especially with the most socially vulnerable groups.

Adherence decision making in the everyday lives of emerging adults with type 1 diabetes

PURPOSE

The purpose of this study was to explore motivations underlying nonadherent treatment decisions made by young adults with type 1 diabetes.

METHODS

Eight emerging adults each completed a series of semi-structured interviews concerning their approaches to diabetes care, relationships with clinicians, and everyday activities and routines. A narrative thematic analysis was used to develop initial themes and refine them through continued data collection and review of the research literature.

RESULTS

FIVE THEMES WERE IDENTIFIED AS MOTIVATING NONADHERENCE: (1) efforts to mislead health care providers, (2) adherence to alternative standards, (3) treatment fatigue and burnout, (4) social support problems, and (5) emotional and self-efficacy problems.

CONCLUSION

Instances of nonadherence generally involved a combination of the five identified themes. Participants reporting nonadherence also described difficulties communicating with care providers regarding their treatment. Nonjudgmental communication between providers and emerging adults may be particularly important in promoting positive health outcomes in this population.

Diabetes and Culture

Diabetes and its many manifestations articulate well with the four-field approach in anthropology, providing an almost seamless example of the relationship between human biology, behavior, society, and culture in both the past and the present tense. In general, publications on diabetes and culture echo Enlightenment philosophies on change and progress that posit the increasing prevalence of diabetes as a “crisis in human relations” ( Bendix 1967 , p. 302) for which culture plays a significant role. The undermining of racial approaches due to what now appears to be diabetes-without-borders has also directed anthropological research into the contingent temporal frameworks of history. The recent attention to society and the social production of the disease may portend the end of culture in research on diabetes and culture.

Concepts of diabetes self-management in Mexican American and African American low-income patients with diabetes

The goal of the study was to explore low-income minority patients' concepts of diabetes self-management and assess the extent to which patient beliefs correspond to evidence-based recommendations. African American and Mexican American patients with type 2 diabetes were recruited from safety net clinics that serve the uninsured and under-insured in Chicago and San Francisco to participate in focus group discussions. Grounded theory was used to identify themes related to diabetes self-management. Strategies participants mentioned for diabetes self-care were medication use, diet, weight loss and exercise. Eating more fruit and vegetables and consuming smaller portions were the most commonly mentioned dietary behaviors to control diabetes. African Americans expressed skepticism about taking medications. Mexican Americans discussed barriers to acquiring medications and use of herbal remedies. Mexican Americans frequently mentioned intentional exercise of long duration as a management strategy, whereas African Americans more frequently described exercise as regular activities of daily living. Blood glucose self-monitoring and reducing risks of diabetes complications were rarely mentioned as diabetes self-management behaviors. African American and Mexican American patients have different concepts of diabetes self-management, especially with regard to medication use and physical activity. Consideration of these differences may facilitate design of effective self-management interventions for these high-risk populations.

Chronic homework in emerging borderlands of healthcare

The task of caring for those with chronic illnesses has gained a new centrality in health care at a global level. We introduce the concept of "chronic homework" to offer a critical reflection on the treatment of chronic illnesses in three quite different national and local contexts: Uganda, Denmark, and the United States. A major challenge for clinicians, patients, and family caregivers is how to navigate the task of moving health care from clinic to home. By "chronic homework," we refer to the work patients and families are expected to carry out in their home contexts as part of the treatment of chronic conditions. Families and patients spend time receiving training by clinical experts in the various tasks they are to do at home. While this "colonization" of the popular domain could easily be understood from a Foucauldian perspective as yet another emerging mode of governmentality, this a conceptualization can oversimplify the way specific practices of homework are re-imagined and redirected by patients and significant others in their home surroundings. In light of this re-invention of homework in local home contexts, we foreground another conceptual trope, describing chronic homework as a borderland practice.

Life values and self-regulation behaviours among adults with type 2 diabetes

AIM

The aim of this study was to identify life values in adults with type 2 diabetes and to describe their experiences of how these values may influence self-regulation behaviours.

BACKGROUND

Daily self-regulation behaviours have been described as challenging, because the individuals try to find a balance between them and life values. However, little is known about how life values may influence the motivation for necessary self-regulation behaviours.

DESIGN AND METHODS

A descriptive/explorative qualitative design that included focus groups was used to collect data. The sample consisted of 19 adults with type 2 diabetes. Data were analysed using qualitative content analysis.

RESULTS

The findings revealed six themes: maintaining health and longevity, a feeling of bodily well-being, preserving a positive body image, self-determination, maintaining the ability to work and belonging. The results reflect the fact that many life values have a major influence on self-regulation behaviours.

CONCLUSIONS

The findings indicate that several of the life values can conflict with self-regulation behaviours, which in turn may influence the motivation for self-regulation of type 2 diabetes. Some of these values could be considered to be related to self-worth, which is regarded as an important motivational component for engaging in a task. Moreover, this study highlights the fact that goals related to self-regulation behaviours were formulated in more general than in specific terms.

RELEVANCE TO CLINICAL PRACTICE

This study may help health professionals to understand how adults' life values influence their motivation for adequate self-regulation. The findings indicate that the existing support structures should make an effort to learn about people's life values and take them into account when giving advice about self-regulation behaviours. Moreover, people with type 2 diabetes should be supported by health professionals to set more specific self-regulation goals that are consistent with their life values.

Perceived support from healthcare practitioners among adults with type 2 diabetes

AIM

This paper is a report of a study of how adults with type 2 diabetes perceive different attributes of support provided by healthcare practitioners and how various attributes of support can influence people's motivation to self-manage their disease.

BACKGROUND

Motivational problems seem to be a major reason for poor diabetes management. According to well-known theories of motivation, expectations of being able to perform certain behaviours are a key element. Different attributes of support from healthcare practitioners are likely to influence such expectations. To date, no researchers have specifically examined how people with type 2 diabetes perceive different attributes of support from healthcare practitioners and how these may influence their motivation to manage their disease themselves.

METHODS

A descriptive/explorative qualitative design and focus groups were used to collect data. The sample consisted of 19 adults with type 2 diabetes, and the data were collected in 2007 and analysed using qualitative content analysis.

FINDINGS

Five themes were identified, reflecting perceived attributes of support from healthcare practitioners: (1) an empathetic approach, (2) practical advice and information, (3) involvement in decision-making, (4) accurate and individualized information and (5) ongoing group-based support.

CONCLUSION

Healthcare practitioners may strengthen the self-management motivation among adults with type 2 diabetes by enhancing expectations of being able to perform the necessary diabetes care, and through the provision of empathetic, individualized, practical and ongoing group-based support.

The experience of self-care: a systematic review

BACKGROUND

Self-care has been defined quite simply as "the set of activities in which one engages throughout life on a daily basis." Examining this 'set of activities' more closely, we see that a number of activities encompass "a person's attempts to promote optimal health, prevent illness, detect symptoms at an early date, and manage chronic illness." Hence, engaging in self-care activities may result in a range of different experiences depending on the set of activities that are performed and the reasons for their undertaking.

OBJECTIVES

To integrate and summarize the experience of engaging in self-care activities as reported by individuals and /or their families.

INCLUSION CRITERIA

Types of Studies - Qualitative studies included, but were not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.Types of Participants - Individuals and/or their families who engaged in self-care activities, or were assisted with their self-care activities, or provided support for self-care.Types of Interventions - Individual experiences of self-care in response to an intervention or where no intervention was introduced.Types of Outcomes - Individual experiences of self-care through self-report. Reports from family members who assisted or provided support for self-care were included.

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished studies (e.g., theses). A three-step search strategy was used in each component of this review. An initial limited search of MEDLINE and CINAHL was undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was then undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles were searched for additional studies. The databases searched included: CINAHL; MEDLINE; EMBASE; PsycINFO; AMED; Cochrane Library; Scirus; and Mednar METHODOLOGICAL QUALITY: Methodological quality of the studies was assessed using the Joanna Briggs Institute Qualitative Assessment and Review Instrument Critical Appraisal Checklist for Interpretive & Critical Research. Two appraisers independently reviewed each study.

DATA COLLECTION AND ANALYSIS

Qualitative data were extracted from included studies using an adaptation of the standardized JBI Data Extraction Tool for Qualitative Evidence.

DATA SYNTHESIS

The data were synthesized using narrative form.

RESULTS AND CONCLUSIONS

Engaging in self-care is a process involving being aware of self, acquiring knowledge and taking responsibility for meeting needs at whatever level they are presented. The performance of self-care behaviours can be influenced both positively and negatively by the attitudes of others. Throughout life, the purpose for performing self-care differs and individuals face challenges that interfere with their ability to master these self-care behaviours. Individuals who are able to find symbolic meaning in the disease/disability or reframe the implications positively are more capable of adapting and maintaining their focus on caring for themselves. Studies revealed that individuals may abandon self-care when overwhelmed by symptoms or disability and/or when they feel that they are not supported.

IMPLICATIONS FOR PRACTICE

It is valuable for health care professionals to understand the struggle that individuals experience when trying to engage in self-care. Furthermore, health care professionals need to be cognizant of how important their support is, in terms of encouraging individuals to adopt and maintain self-care behaviours.

IMPLICATIONS FOR RESEARCH

This review has provided an insight into the process of engaging in self-care through the different developmental stages of life, as well as the adoption of self-care behaviours to meet different requisites. Further research would be valuable to integrate the range of health care interventions provided to individuals across different disability or disease groupings who engage in self-care activities.

"Worried all the time'': distress and the circumstances of everyday life among immigrant Australians with type 2 diabetes

People with diabetes commonly experience emotional distress and are often diagnosed with depression. To explore lay accounts of the conditions and social aspects of their co-occurrence, we draw on qualitative research conducted in metropolitan Melbourne, Australia. Data derive from in-depth interviews with men and women from Greek, Chinese, Indian and Pacific Island communities, all of which have a higher than average incidence of type 2 diabetes mellitus. Participants generally saw stress as a precursor to diabetes, influencing their ability to control symptoms. Yet they also emphasized that life adversities, trauma, disruption, and multiple losses caused distress and depression. Participants regarded diabetes as an illness that interrupted their ability to carry out everyday living tasks. This contributed to their social isolation and unsettled self-identity, resulting in feelings of personal inadequacy, loss and further distress. These themes were common across immigrant groups.

The Elephant in the Room: The Invisibility of Poverty in Research on Type 2 Diabetes

Over two hundred years of anecdotal, epidemiological, and experimental evidence indicate that poverty breeds disease. This holds true for type 2 diabetes, which both in the United States and other developed nations disproportionately occurs, cripples, and kills among the poor. In this article we examine rhetorical strategies used in 30 journal articles indexed under type 2 diabetes and poverty. As we show, poverty is rarely highlighted in this literature as a causal factor. Instead, explanations for diabetes among poor people overwhelmingly emphasize features of patients—their biology, behaviors, psychology, culture, or other “risk factors”—while ignoring, reframing or neglecting the links between poverty and disease. By so doing, these discursive strategies naturalize higher rates of diabetes among poor persons, legitimize relations of domination in the larger society, and encourage only research projects, treatment practices and health and social policies that do not challenge existing social relations. We discuss the implications of these discursive practices for medical research and care, and for social and public health policies.

Identifying health-related quality of life (HRQL) domains for multiple chronic conditions (diabetes, hypertension and dyslipidemia): patient and provider perspectives

OBJECTIVE

To examine patient and provider perspectives about the impact of having diabetes, hypertension and/or dyslipidemia (DHD) on health-related quality of life (HRQL) in order to identify domains for an HRQL instrument focusing on specific chronic diseases (DHD).

STUDY DESIGN

Exploratory qualitative design was used to elicit patient and provider responses. Patient survey contained 11 demographic and nine content questions inquiring how the disease(s) affected patient HRQL. Provider survey examined how the disease(s) affected their patient's HRQL and crucial factors for improvement. Patients were included if they had DHD and spoke English. Providers working with DHD patients were identified among university faculty and community practitioners.

RESULTS

Thirty-eight patients (24.7%) completed the interviews. Three judges content analysed patient responses and proposed seven categories (patients ranked physical functioning first followed by diet, emotional well-being (E), general well-being, social functioning (S), 'no change in HRQL' and medications). One question about medications had four categories (medication inconvenience, medication side effects, forgetfulness and general well-being). Index for reliability was greater than 80% for all categories. Providers ranked lifestyle modification (LM), first followed by complications, medication, self-care, E, education, S, physical activity and resources (ability to pay) as components that impact HRQL.

CONCLUSIONS

Patient and provider perspectives were similar in four areas (E, S, medication and diet); however, the differences were in how these impacted HRQL - patients focused on activities relevant to daily life that were affected, while providers based it on processes of therapy management and self-care (education and implementation of LM).

Psychological insulin resistance: patient beliefs and implications for diabetes management

PURPOSE

To define and understand patient psychological insulin resistance (PIR) and its impact on diabetes management.

METHODS

Systematic literature review of peer-refereed journals using the MEDLINE database, including all articles in English from 1985 to 2007. The population included patients with type 1 and type 2 diabetes, insulin naïve, and those currently using insulin. A total of 116 articles were reviewed.

RESULTS

PIR is impacted by patients' beliefs and knowledge about diabetes and insulin, negative self-perceptions and attitudinal barriers, the fear of side effects and complications from insulin use, as well as lifestyle adaptations, restrictions required by insulin use, and social stigma. These etiological influences, both independently and in combination, constitute a patient's PIR and may result in the reluctance of patients to both initiate and intensify treatment, leading to delayed treatment initiation and compromised glucose control.

CONCLUSIONS

PIR is complex and multifaceted. It plays an important, although often ignored, role in diabetes management. Assisting health care professionals in better understanding PIR from the patient's perspective should result in improved treatment outcomes. By tailoring treatments to patients' PIR, clinicians may be better able to help their patients begin insulin treatment sooner and improve compliance, thus facilitating target glycemic control.

Patient-provider perceptions of diabetes and its impact on self-management: a comparison of African-American and White patients

AIMS

To compare patient-provider differences in diabetes-related perceptions between African-American and White patients and to examine its association with self-care behaviours.

METHODS

One hundred and thirty patient-provider pairs were recruited from the greater Detroit area. Patients and providers completed a survey assessing perceptions about diabetes-related concepts and demographic background. The Diabetes Semantic Differential Scale was used to measure diabetes-related perceptions. Patients also reported the frequency of performing self-care behaviours, including following a healthy eating plan, engaging in physical activity, blood glucose monitoring, and taking medication and/or insulin.

RESULTS

There were a greater number of patient-provider differences in diabetes-related perceptions for the African-American patients (nine of 18 concepts) compared with the White patients (four of 18 concepts). Stepwise regression analyses found patients' semantic differential scores to be significantly associated with five self-care behaviours for African-American patients and two self-care behaviours for White patients. Providers' semantic differential scores emerged as predictors of self-care behaviours for African-American patients, but not for White patients.

CONCLUSIONS

Our findings suggest that compared with White patients, African-Americans differ in a greater number of diabetes-related perceptions than their providers. Patients' and providers' perceptions of diabetes care concepts have a significant impact on a greater number of self-care behaviours for African-American patients than White patients.

Patient and provider perceptions of diabetes: measuring and evaluating differences

OBJECTIVE

This study measures diabetes care perceptions of patients and their providers, and examines perceptions differences of patient-provider pairs.

METHODS

Patient and provider perceptions were assessed using the Diabetes Semantic Differential Scales (DSDS) which ask respondents to rate diabetes care concepts using contrasting adjective pairs. The DSDS was scored by two methods: using means and using factor analysis. Persons with diabetes 40-years-old or older were recruited. Using a "snowball" sampling strategy, potential provider participants were identified by their patients; 71 providers agreed. These providers represented 51% of the patient participants and created 138 patient-provider pairs.

RESULTS

For the mean scores, there were significant differences between patients and providers for 5 of the 18 semantic differentials (28%). Similarly, the factor scores indicated significant differences for 14 of 54 factors (26%). The effect sizes indicated practical differences.

CONCLUSION

Significant differences exist between patient and provider perceptions. Generally, patients have the more positive diabetes perceptions.

PRACTICE IMPLICATIONS

During patient and provider discussions, participants can perceive diabetes concepts differently. The DSDS can determine perception differences. While it is best to use factor analyses to score the DSDS, mean scores are more easily calculated and indicate the broad conceptual areas where patient and provider differ.

Preferences for self-management support: findings from a survey of diabetes patients in safety-net health systems

OBJECTIVE

We sought to identify interest in different modes of self-management support among diabetes patients cared for in public hospitals, and to assess whether demographic or disease-specific factors were associated with patient preferences. We explored the possible role of a perceived communication need in influencing interest in self-management support.

METHODS

Telephone survey of a random sample of 796 English and Spanish-speaking diabetes patients (response rate 47%) recruited from four urban US public hospital systems. In multivariate models, we measured the association of race/ethnicity, primary language, self-reported health literacy, self-efficacy, and diabetes-related factors on patients' interest in three self-management support strategies (telephone support, group medical visits, and Internet-based support). We explored the extent to which patients believed that better communication with providers would improve their diabetes control, and whether this perception altered the relationship between patient factors and self-management support acceptance.

RESULTS

Sixty-nine percent of respondents reported interest in telephone support, 55% in group medical visits, and 42% in Internet. Compared to Non-Hispanic Whites, Spanish-speaking Hispanics were more interested in telephone support (OR 3.45, 95% CI 1.97-6.05) and group medical visits (OR 2.45, 95% CI 1.49-4.02), but less interested in Internet self-management support (OR 0.56, 95% CI 0.33-0.93). African-Americans were more interested than Whites in all three self-management support strategies. Patients with limited self-reported health literacy were more likely to be interested in telephone support than those not reporting literacy deficits. Forty percent reported that their diabetes would be better controlled if they communicated better with their health care provider. This perceived communication benefit was independently associated with interest in self-management support (p<0.001), but its inclusion in models did not alter the strengths of the main associations between patient characteristics and self-management support preferences.

CONCLUSION

Many diabetes patients in safety-net settings report an interest in receiving self-management support, but preferences for modes of delivery of self-management support vary by race/ethnicity, language proficiency, and self-reported health literacy.

PRACTICE IMPLICATIONS

Public health systems should consider offering a range of self-management support services to meet the needs of their diverse patient populations. More broad dissemination and implementation of self-management support may help address the unmet need for better provider communication among diabetes patients in these settings.

“Diabetes is my companion”: Lifestyle and self-management among good and poor control Mexican diabetic patients

This paper identifies naturally occurring lifestyle and self-care practices in managing type 2 diabetes mellitus that are associated with good glycemic control. In-depth, qualitative interviews were conducted in Guadalajara, Mexico, with 31 matched pairs of good and poor control diabetic patients (n=62), who were matched on their duration of disease and use of medications. While many themes were listed by both groups, a comparison of the responses indicated that themes of daily exercise with a preference for walking, eating beef and milk rather than chicken and fish, economic issues, and emotional issues distinguished poor-control patients. Good-control patients were more likely to have a negative reaction to their initial diagnosis, take a more comprehensive approach to control, eat only two meals a day (plus snacks), use noncaloric beverages to satisfy desires for more food, and know what their blood sugar levels should be.

Relationships and their potential for change developed in difficult type 1 diabetes

Few researchers have explored how relationships between patients and providers might change problem solving in clinical practice. The authors used grounded theory to study dyads of 11 people with diabetes and poor glycemic control, and 8 nurses interacting in diabetes teams. Relational Potential for Change was identified as a core category that involved three types of relationships. Professionals mostly shifted between less effective relationships characterized by I-you-distant provider dominance and I-you-blurred sympathy. Although rarely seen, a third relationship, I-you-sorted mutuality proved more effective than the others in exploiting the Relational Potential for Change. The three types of relationship differed in (a) scope of problem solving, (b) the roles assigned to the patient and the professionals, (c) use of difficult feelings and different points of view, and (d) quality of knowledge achieved as the basis for problem solving and decision making. The authors discuss implications for practice and further research.

Sero-positive African Americans' beliefs about alcohol and their impact on anti-retroviral adherence

Alcohol consumption has been associated with HIV disease progression; yet, the nature of this association is poorly understood. This study sought to determine the influence of patient beliefs about alcohol on ART adherence, and elucidate clinician beliefs about drinking and taking ART. Most patients (85%) believed alcohol and ART do not mix. The three alcohol consumption groups, light, moderate, and heavy, differed in their beliefs about drinking and ART with 64% of light and 55% of moderate drinkers skipping ART when drinking compared to 29% of heavy drinkers. Beliefs were derived from folk models of alcohol-ART interaction. Patients 50 and older were less likely to skip ART when drinking. Alcohol appears to affect adherence through decisions to forgo ART when drinking not through drunken forgetfulness. Furthermore, over one-half of clinicians believed alcohol and ART should not be taken together. These findings have implications for patient care and physician training.

What employees with diabetes mellitus need to cope at work: views of employees and health professionals

OBJECTIVE

To identify and compare patient and professional perspectives on what enables employees with diabetes mellitus (DM) to maintain their position in the workplace. To provide information on how professionals can help DM patients cope at work.

METHODS

Qualitative study using concept-mapping sessions involving 23 employees with DM and 22 health professionals (GP's, occupational physicians and specialists). All of the health professionals were experts in the field of diabetes care.

RESULTS

Patients and professionals identified five common clusters of statements on what diabetics need to enable them to cope at work: the ability to accept and cope with DM, supportive health professionals, a supportive work environment, work adaptations and good information. Patients emphasized the importance of emotional acceptance of DM and communication with colleagues, while the professionals emphasized the patient's capacity for self-care.

CONCLUSION

The content of patient and professional perspectives on what is needed to prevent work-related problems for DM patients differed slightly. Patients rely on direct experiences in their own environment, professionals on medical knowledge accumulated in groups of patients.

PRACTICE IMPLICATIONS

Both perspectives were used to suggest a topic list for health professionals, which may help identify and address the occupational problems experienced by DM patients.

Vulnerable Populations with Diabetes Mellitus

This review of the literature on vulnerable populations with diabetes identifies trends, summarizes major findings, and recommends strategies to fill gaps in the state of the science. For the purposes of this article "vulnerable populations" refers to members of diverse racial and ethnic groups, people of low-income, and those who live in rural and medically underserved areas.

How qualitative methods contribute to understanding combination antiretroviral therapy adherence

Strict adherence to medication regimens is generally required to obtain optimal response to combination antiretroviral therapy (ART). Yet, we have made limited progress in developing strategies to decrease the prevalence of nonadherence. As we work to understand adherence in developed countries, the introduction of ART in resource-poor settings raises novel challenges. Qualitative research is a scientific approach that uses methods such as observation, interviews, and verbal interactions to gather rich in-depth information about how something is experienced. It seeks to understand the beliefs, values, and processes underlying behavioral patterns. Qualitative methods provide powerful tools for understanding adherence. Culture-specific influences, medication beliefs, access, stigma, reasons for nonadherence, patterns of medication taking, and intervention fidelity and measurement development are areas ripe for qualitative inquiry. A disregard for the social and cultural context of adherence or the imposition of adherence models inconsistent with local values and practices is likely to produce irrelevant or ineffective interventions. Qualitative methods remain underused in adherence research. We review appropriate qualitative methods for and provide an overview of the qualitative research on ART nonadherence. We discuss the rationales for using qualitative methods, present 2 case examples illustrating their use, and discuss possible institutional barriers to their acceptance.

Control and adherence: Living with diabetes in Bangkok, Thailand

Diabetes is managed via a regimen of control. Physicians advise adults living with type 2 diabetes to control blood sugar levels by controlling diet, maintaining regular exercise, and complying with medication. The extent to which individuals are able to adhere to such recommendations varies. In this article, we explore lay perceptions of diabetes and its control, drawing on data from an ethnographic study conducted in Bangkok, Thailand. Between August 2001 and February 2003 the first author spent time with twelve man and women living with type 2 diabetes, their spouses, children and health providers. An additional 21 people were interviewed to extend the data and test for generalisibility. It was found that individual explanations of control, and adherence or resistance to medical advice, are interpreted and adapted in ways consistent with Buddhist philosophy and Thai norms that govern everyday life. Notions of moderation and cultural values of being and behaving, and ideals of interaction, provide a philosophical basis and practical guidelines for control.

What is effective intervention? – using theories of health promotion

The NHS must be smoke free by the end of 2006 (Department of Health, 2004). The necessary elements to introducing a smoke-free policy, which is workable and equitable, are the management of the policy and offering support to smokers. Smoking and second-hand smoking are responsible for many illnesses, premature deaths and reduced productivity. Employers have a responsibility to ensure the health of their employees by protecting them from exposure to cigarette smoke in the workplace. Although smoking restrictions in the workplace are popular, it is important to ensure good communication with everyone who will be affected, since there are many fears associated with the introduction of the policy. Help must be offered to people who wish to quit through behavioural and pharmacological interventions and support must also be given to the smoker who must abstain from smoking on the premises during work or hospital stay.

Diabetes beliefs among low-income, white residents of a rural North Carolina community

CONTEXT

Every social group shares beliefs about health and illness. Knowledge and understanding of these health beliefs are essential for education programs to address health promotion and illness prevention.

PURPOSE

This analysis describes the diabetes Explanatory Models of Illness (EMs) of low-income, rural, white Southerners who have not been diagnosed with diabetes.

METHOD

In-depth interviews were conducted with low-income white women (n = 19) and men (n = 20) aged 18 to 54 years who resided in a rural Southern town. The tape-recorded interviews were completed by trained interviewers and were transcribed verbatim. Computer-assisted text analysis was used, and all transcripts were coded by 2 investigators.

FINDINGS

Although all the participants had heard of diabetes, their EMs were vague and undeveloped. Women were more knowledgeable than men were. Family and heredity were widely believed to be causes, with heredity including genetic and learned behavior components. Participants disagreed about the role of diet and weight in causing diabetes; exercise was not perceived as related to causation. Participants had knowledge of those symptoms, complications, and treatments that could be observed.

CONCLUSIONS

These rural, white Southerners did not share well-developed EMs for diabetes, with most having a vague and incomplete understanding of this disease. The diabetes beliefs of these rural Southerners differ significantly from current medical knowledge. To be effective, culturally appropriate primary prevention programs must recognize these lay beliefs.

Patients with diabetes speak: exploring the implications of patients' perspectives for their diabetes appointments

Type 2 diabetes puts patients at risk for serious health consequences that they can prevent or delay by achieving glycemic control. However, glycemic control depends largely on self-management. Consequently, determining what physicians might do in medical appointments to improve patients' self-management is of utmost concern. Patients were asked to discuss, in focus groups, their illness experience and their goals for regularly scheduled appointments. Six interrelated themes emerged from the analysis of transcripts: complications and comorbidities, time, control, information, family influences, and the physician-patient encounter. These themes and their implications for diabetes appointments were explored, specifically considering how physicians might use information about patients' perspectives to improve patients' self-management and thereby their glycemic control.

Understanding the diabetic body-self

Diabetes is the sixth leading cause of death from disease, shortens the average life span by up to 15 years, and is the main cause of new blindness, kidney failure, and amputations in the United States. Interviews with 2 practitioners and 8 individuals with diabetes illustrate how individuals embody their illness. Interviewed persons with diabetes tended to be most closely associated with the disciplined body type and pursued high levels of bodily control, in contrast to an idealized type, the communicative body, which can be considered an ethical ideal. This framework provides heuristic value by providing insight into the behaviors, needs, and struggles of persons with diabetes, as well as providing a means to more effective treatment and better practitioner-patient relationships.

Living After External Beam Radiotherapy of Localized Prostate Cancer

The treatment of prostate cancer induces adverse effects. Although quantitative studies have evaluated the influence of these adverse effects on the quality of life, few studies have tried to gain a deeper understanding of how men live after external beam radiotherapy of localized prostate carcinoma, which is the purpose of this study. Ten men were interviewed in their homes. The narrative interviews were tape recorded and transcribed into a text. The text was analyzed qualitatively by a content analysis. To bear the emotional experience of the illness by oneself is a self-chosen strategy. Some men expressed a sense of being exposed in meetings with female caregivers. The treatment induced changes in body functions influencing daily life. In this new life situation these men are striving to reach a sense of having control, which includes control over disease progression and waning body function. Despite the negative influence of the treatment, the men are striving to become reconciled with their new life. The experience of living after external beam radiotherapy of localized prostate carcinoma could be understood as striving to reach a sense of control and becoming reconciled with a new way of life.