Facilitators, barriers and needs in the self-management of type 2 diabetes

Facilitators, barriers and needs in the self-‐management of

type 2 diabetes

A qualita;ve study with Portuguese pa;ents

Liliana Laranjo 1, Ana Luisa Neves 2, Alexandra Costa 3, Rogério Ribeiro 3

1 Portuguese School of Public Health 2 Departamento de Ciências Sociais e Saúde / FMUP 3 Associação Protectora dos Diabé;cos de Portugal

EGPRN ATard , Malta 2013

6.4%¹ 7.7%¹ (2010) (2030)

6.5% ² 11.7% ³ (2006) (2009)

1)  Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: es;mates for the year 2000 and projec;ons for 2030. Diabetes Care. 2004 May;27(5):1047-‐53

2)  Inquérito Nacional de Saúde, 2006 3)  PREVADIAB – SPD. Estudo da prevalência da diabetes em Portugal, 2009.

Diabetes Mellitus -‐ Prevalence -‐

Facilitators, barriers and needs in the self-‐management of type 2 diabetes

Results Discussion Methods Background Implica;ons

  Portugal (2008)¹ •  0.7% of the GDP •  7% of total health expenditure

  50% of Portuguese diabe;cs do not reach metabolic control²

Diabetes Mellitus -‐ Importance in Portugal -‐

1)  Diabetes: factos e números, 2009. Relatório anual do Observatório Nacional da Diabetes. Observatório Nacional da Diabetes, 2009 2)  Falcão I, Pinto C, Santos J, Fernandes M, Ramalho L, et al. Estudo da prevalência da diabetes e das suas complicações numa coorte de diabé;cos portugueses: um estudo na Rede Médicos-‐Sen;nela. Rev Port Clin

Geral. 2008;24:679-‐92




Pa4ent factors: • Age • Gender • Level of educa;on • Socio-‐economic level • Health literacy • Digital literacy • Lifestyle • Social support • Co-‐morbidi;es • Weight and BMI

Adherence to medica4on

Structure of care: • Primary care organiza;onal factors • EMRs in use • Par;culari;es of each health care center • Access to DM consulta;ons and health care

Process of care: • Consulta;ons

• Health informa;on and advice

• Treatment (side effects, regimen burden...)

Diabetes symptoms

Self-‐management

Metabolic control

Blood pressure

LDLc

Disease-‐related factors: •  DM dura;on •  Treatment (side effects, regimen burden...)



Pa4ent factors: • Age • Gender • Level of educa;on • Socio-‐economic level • Health literacy • Digital literacy • Lifestyle • Social support • Co-‐morbidi;es • Weight and BMI

Adherence to medica4on

Structure of care: • Primary care organiza;onal factors • EMRs in use • Par;culari;es of each health care center • Access to DM consulta;ons and health care

Process of care: • Consulta;ons

• Health informa;on and advice

• Treatment (side effects, regimen burden...)

Diabetes symptoms

Self-‐management

Metabolic control

Blood pressure

LDLc

Disease-‐related factors: •  DM dura;on •  Treatment (side effects, regimen burden...)


1 hour/year with the physician

8700 hours/year of self-‐management

Mohammad Al-‐Ubaydli. Personal Health Rcords: a guide to clinicians. Wiley-‐Blacwell



Tricco, A.C., et al., Effec%veness of quality improvement strategies on the management of diabetes: a systema%c review and meta-‐analysis. Lancet, 2012. 379(9833): p. 2252-‐61



Effect on HbA1c



Research ques4on

What are the facilitators, barriers and needs in the self-‐

management of type 2 diabetes (perceived by pa;ents)?



Par4cipants •  Adult pa;ents with type 2 diabetes (for at least 1 year) •  Portuguese Diabetes Associa;on

•  Survey (demographic and disease-‐related informa;on)

Focus groups •  3 focus groups (4-‐6 par;cipants each), 45-‐60 min each •  N = 15 pa;ents •  Moderator + assistant



Interview guide


Data analysis •  Debriefing and analysis of notes awer each

session •  Videotapes transcribed verba;m •  Satura;on was achieved at the third session •  NVivo •  Done independently by 2 inves;gators •  Grounded theory was used to iden;fy the

themes •  Constant-‐compara;ve method •  Nodes clustered in major themes





Knowledge / informa;on Family and social aspects

Barriers

Diet Physical exercise

Glycemic control

Facilitators and needs




Barriers


Glycemic control




Diet

Quality

€ € Cravings Specific recipes

Quan;ty

Por;on size

Schedule

Rigid meal schedule

Intrinsic

Mo;va;on

Knowledge / informa;on (confusion, myths, lack of specific knowledge)

Family and social aspects (holidays, social events, cooking for others)

Barriers




“I try to have a healthy diet – but some;mes is difficult. Some;mes is really very difficult, in social dinners or lunches. One cannot manage it. (…) Trying to have a

healthy diet was the most difficult thing, the hardest thing.”

“My biggest struggle is the diet because I enjoy ea;ng.”

“I think that the biggest problem is not having the mo;va;on to have a healthy diet.”



Barriers


Glycemic control




Physical exercise

Pain Fa;gue Behavior Change

Co-‐ morbidi;es

Knowledge / informa;on (specific types of recommended ac;vi;es)

Family and social aspects (lack of family and friend support)

Barriers



Barriers


“The family can either help or make things more difficult. My daughter is always worried with me and might call me five ;mes a day saying “eat this, don’t eat that”.

My husband is the opposite, always telling me to taste this and that.”



Barriers


Glycemic control




Glycemic control

Discomfort measuring

Diet mistakes Stress

Knowledge / informa;on (confusion about sudden rises in glycemia)

Family and social aspects (lack of family and friend support)

Barriers




Barriers


Glycemic control





Knowledge / informa;on •  Family members and friends with diabetes •  Own experience •  Healthcare professionals •  Booklets and magazines from the Portuguese Diabetes Associa;on •  Media (television, magazines…)

Family and social support





“There is not enough informa;on – there should be more, is a disease that affects so many people.”

(about a healthy diet) “it is not too difficult because my wife and my kids help me with that at home”

“If it wasn’t for the friend that goes walking with me, I wouldn’t go. But then she mo;vates me and I end up going.”



•  Lifestyle behavior change was the hardest part of self-‐managing the disease, for the majority of par;cipants.

•  Diet was the most problema;c self-‐management behavior.

•  Adhering to oral medica;on didn’t seem to be a problem.

•  Pa;ents seem to lack specific informa;on about diet and exercise that could help them implement strategies for behavior change.



Related literature

•  Diet is the most problema;c self-‐management behavior 1 2

•  The cost of a healthy diet is a significant barrier 2

•  There is lack of specific knowledge about diet and exercise 3 4

•  Family can be either a facilitator or a barrier 5

1)  Hill-‐Briggs F, Cooper DC, Loman K, Branca; FL, Cooper LA. A qualita;ve study of problem solving and diabetes control in type 2 diabetes self-‐management. Diabetes Educ. 2003 Nov-‐Dec;29(6):1018-‐28 2)  Vijan S, Stuart NS, Fitzgerald JT, Ronis DL, Hayward RA, Slater S, et al. Barriers to following dietary recommenda;ons in Type 2 diabetes. Diabet Med. 2005 Jan;22(1):32-‐8

3)  Lynch EB, Fernandez A, Lighthouse N, Mendenhall E, Jacobs E. Concepts of diabetes self-‐management in Mexican American and African American low-‐income pa;ents with diabetes. Health Educ Res. 2012 Oct;27(5):814-‐24

4)  Peytremann-‐Bridevaux I, Lauvergeon S, MeTler D, Burnand B. Diabetes care: Opinions, needs and proposed solu;ons of Swiss pa;ents and healthcare professionals: a qualita;ve study. Diabetes Res Clin Pract. 2012 Aug;97(2):242-‐50

5)  Carbone ET, Rosal MC, Torres MI, Goins KV, Bermudez OI. Diabetes self-‐management: perspec;ves of La;no pa;ents and their health care providers. Pa;ent Educ Couns. 2007 May;66(2):202-‐10 6)  Mayberry LS, Osborn CY. Family support, medica;on adherence, and glycemic control among adults with type 2 diabetes. Diabetes Care. 2012 Jun;35(6):1239-‐45


Limita4ons

•  Generalizability

•  Number of par;cipants

•  Number of focus groups / satura;on

•  Context -‐ usual place of care (ability to speak freely?)




•  For healthcare providers

•  Barriers to self-‐management should be addressed frequently, as some of them have the poten;al to be overcome if a specific strategy is implemented.

•  For Policy Makers

•  Cost of a health diet

[email protected] @LilianaLaranjo


Date post:	28-Jan-2015
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Facilitators, barriers and needs in the self-management of type 2 diabetes

Health & Medicine