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
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Results Discussion Methods Background Implica;ons
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
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...)
Results Discussion Methods Background Implica;ons
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
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...)
Results Discussion Methods Background Implica;ons
1 hour/year with the physician
8700 hours/year of self-‐management
Mohammad Al-‐Ubaydli. Personal Health Rcords: a guide to clinicians. Wiley-‐Blacwell
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Results Discussion Methods Background Implica;ons
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
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Results Discussion Methods Background Implica;ons
Effect on HbA1c
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Results Discussion Methods Background Implica;ons
Research ques4on
What are the facilitators, barriers and needs in the self-‐
management of type 2 diabetes (perceived by pa;ents)?
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Results Discussion Methods Background Implica;ons
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
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Results Discussion Methods Background Implica;ons
Interview guide
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
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
Results Discussion Methods Background Implica;ons
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Results Discussion Methods Background Implica;ons
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Knowledge / informa;on Family and social aspects
Barriers
Diet Physical exercise
Glycemic control
Facilitators and needs
Results Discussion Methods Background Implica;ons
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Knowledge / informa;on Family and social aspects
Barriers
Diet Physical exercise
Glycemic control
Facilitators and needs
Results Discussion Methods Background Implica;ons
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
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
Results Discussion Methods Background Implica;ons
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Results Discussion Methods Background Implica;ons
“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.”
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Knowledge / informa;on Family and social aspects
Barriers
Diet Physical exercise
Glycemic control
Facilitators and needs
Results Discussion Methods Background Implica;ons
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
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
Results Discussion Methods Background Implica;ons
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Barriers
Results Discussion Methods Background Implica;ons
“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.”
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Knowledge / informa;on Family and social aspects
Barriers
Diet Physical exercise
Glycemic control
Facilitators and needs
Results Discussion Methods Background Implica;ons
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
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
Results Discussion Methods Background Implica;ons
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Knowledge / informa;on Family and social aspects
Barriers
Diet Physical exercise
Glycemic control
Facilitators and needs
Results Discussion Methods Background Implica;ons
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Facilitators and needs
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
Results Discussion Methods Background Implica;ons
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Facilitators and needs
Results Discussion Methods Background Implica;ons
“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.”
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Results Discussion Methods Background Implica;ons
• 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.
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Results Discussion Methods Background Implica;ons
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
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Limita4ons
• Generalizability
• Number of par;cipants
• Number of focus groups / satura;on
• Context -‐ usual place of care (ability to speak freely?)
Results Discussion Methods Background Implica;ons
Facilitators, barriers and needs in the self-‐management of type 2 diabetes
Results Discussion Methods Background Implica;ons
• 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
Facilitators, barriers and needs in the self-‐management of type 2 diabetes