Type 2 Diabetes Patients' Perspectives, Experiences, and Barriers Toward Diabetes-Related Self-Care: A Qualitative Study From Pakistan

Modified risk calculator for the Pakistani population based on perceived versus actual risk factors for developing type 2 diabetes mellitus

Purpose

The purpose of this study was to develop the modified risk calculator for the Pakistani population based on differences in perceived versus actual risk factors for developing type 2 diabetes mellitus (T2-DM).

Design/methodology/approach

A cross-sectional study design was developed to assess the study sample of 296 individuals from the Pakistani population. The data was collected using a questionnaire divided into three parts: general health, the validated Risk Perception Survey for Developing Diabetes (RPS-DD) and actual T2-DM risk assessment.

Findings

The study findings showed that among the total participants, 70.27% reported a low perceived risk of developing T2-DM, whereas 29.72% reported a high perceived risk when considering their family history. Regarding actual risk, males showed a 59% higher likelihood of developing T2-DM than females, who have a 50% higher risk. The modified calculator includes physical activity, fatty food consumption, age 34–65 and over 65, depression and artificially sweetened beverages.

Research limitations/implications

This study experienced limited representativeness; many participants provided incomplete nutritional and knowledge information. It involved 296 individuals, mostly from one province and a few from other provinces of Pakistan. Therefore, the results can be generalized to the whole Pakistani population.

Practical implications

This study underscores the need for targeted interventions to enhance risk perception, inform preventive strategies and further investigate the interplay between perceived and actual risks in T2-DM in Pakistan.

Social implications

The outcomes of this study can help Pakistani individuals who perceive themselves at an elevated risk of developing T2-DM. There is a general awareness among the Pakistani population regarding T2-DM. In contrast to perceived risk, the data on actual risk reveals a significant disconnect.

Originality/value

In Pakistan, there is a lack of research on perceived versus actual risk factors for developing T2-DM. To the best of the authors’ knowledge, this is the first study that evaluates the actual risk factors of developing T2-DM based on culture and dietary diversity in Pakistan.

Perceived Barriers to Healthy Lifestyle Adherence and Associated Factors Among Patients with Type 2 Diabetes Mellitus: Implications for Improved Self-Care

Background

Many patients with type 2 diabetes mellitus (T2DM) face barriers to maintain a healthy lifestyle. This study investigated the perceived barriers to healthy eating and physical activity and compared them by demographic and diabetes-related characteristics among patients with T2DM.

Methods

A cross-sectional study was conducted among 534 patients with T2DM attending primary healthcare centers in Hail City from January to June 2023. Data analyzed at a significance level of <0.05.

Results

Barriers to healthy eating and physical activity were perceived by 34.9% and 28% of patients, re-spectively. Personal and environmental barriers to healthy eating were perceived more frequently than social barriers (43.0% and 26.9%, respectively). Personal and environmental barriers to physical activity were perceived by 28.0% of patients, followed by social barriers (27.9%). The most frequently perceived barrier to healthy eating was a lack of motivation (61.6%), followed by insufficient information about healthy diets (32.2%). Regarding physical activity, a lack of motivation was the most frequently perceived personal barrier (32.0%), while a lack of a supportive work environment was the most frequently perceived social barrier (33.7%). Patients who were aged between 30 and 40 years, were highly educated, were diagnosed with DM within less than five years, and used insulin injections as a strategy to manage DM reported significantly higher levels of perceived barriers to healthy eating compared to their counterparts. In contrast, patients who were female, married, had poor financial status, and used insulin injections reported significantly higher levels of perceived barriers to physical activity compared to their counterparts.

Conclusion

Over one-third of patients with T2DM seeking medical care in Hail City perceive barriers to healthy eating, mainly a lack of motivation, insufficient diet information. Educational programs that consider the unique characteristics of patients should be developed.

Synthesis of arylated tetrahydrobenzo[H]quinoline-3-carbonitrile derivatives as potential hits for treatment of diabetes

Aim: Quinoline scaffolds are serving as the core structure for numerous antifungal, analgesic, antipyretic, anti-inflammatory drugs as well as have also been investigated for their potential antidiabetic properties. Though further exploration is required in this area as the current antidiabetic agents, such as acarbose, miglitol and voglibose, are associated with several adverse side effects. In this context, arylated tetrahydrobenzo[H]quinoline-3-carbonitrile derivatives were designed and evaluated as potential antidiabetic agents.Materials & methods: A one-pot multicomponent reaction of 6-methoxy-1-tetralone with ethyl cyanoacetate, ammonium acetate and varying aldehydes yielded a range of new arylated tetrahydrobenzo[h]quinoline-3-carbonitrile molecules 1-36.Results: Compounds 2-5, 12, 13, 19 and 32-34 showed excellent inhibition against α-amylase (IC50 = 3.42-15.14 μM) and α-glucosidase (IC50 = 0.65-9.23 μM) enzymes in comparison to the standard acarbose (IC50 = 14.35 μM). In addition, all compounds revealed significant to moderate DPPH radical scavenging activity (SC50 = 21.30-138.30 μM) compared with BHT (SC50 = 64.40 μM). Kinetic studies confirmed competitive inhibition mode, while molecular docking studies comprehend ligands' interaction with enzyme's active sites and absorption, distribution, metabolism, and excretion analysis confirms that all synthetic derivatives are nontoxic.Conclusion: This research offers a range of lead candidates to become antidiabetic agents after further advanced study.

Perspectives of patients with type 1 and type 2 diabetes on barriers to diabetes care: a qualitative study

BACKGROUND

Diabetes care incorporates multiple integrated elements like self-care practices, patient education and awareness, societal support, equitable access to healthcare facilities and trained healthcare professionals, commitment from the diabetes associations and government policies. There is a dearth of research exploring the barriers experienced by both People with Type 1 diabetes (PwT1D) and People with Type 2 diabetes (PwT2D) in accessing the holistic elements of diabetes care. This study thus aimed at exploring the perceived barriers among PwT1D and PwT2D in accessing diabetes care services in urban and rural areas of Nepal.

METHOD

This study was a qualitative research using phenomenological approach where an in-depth interview with 23 participants on insulin was conducted. This included 15 PwT1D and 8 PwT2D, residing in the capital and rural areas and attending the hospitals and clinic in the urban and semi-urban regions in Nepal. A semi-structured questionnaire was used for the interview. The interviews were transcribed verbatim and deductive thematic analysis was done.

RESULTS

Majority were female participants and most had received a formal education and were visiting the hospitals located in capital city. Mean age for PwT1D was (27.86 ± 1.85) years whereas the median age for PwT2D was [47.5 (IQR, 16.5)] years. Seven themes were generated from the study representing key barriers from patient's perspective. These were: Theme (1) Double stigma: Diabetes diagnosis and insulin use, Theme (2) Non-adherence to insulin and Self-Monitoring of Blood Glucose (SMBG), Theme (3) Logistic challenges in rural areas: Scarcity of healthcare professionals and other healthcare facilities, Theme (4) Dissatisfaction with healthcare services, Theme (5) Patients seeking alternative treatment strategies over allopathic treatment, Theme (6) Limitations of health insurance scheme and Theme (7) Limited role of national diabetes organizations.

CONCLUSION

There is a need in raising awareness among general public especially on T1DM to address the issue of diabetes stigma. An effort in implementation of policies supporting diabetes care and refinement of National Health Insurance Scheme is equally essential. Similarly, strengthening of Health Care System by ensuring availability of insulin, laboratory facilities and trained healthcare professionals in rural areas should be focused to address the inequity in access to healthcare in rural and urban sectors.

Evaluating Risk Factors and the Burden of Silent Myocardial Ischemia Among Diabetic Patients

INTRODUCTION

Silent myocardial ischemia (SMI) is a significant concern for diabetic patients, often remaining undetected until severe complications arise. Prolonged hyperglycemia, poor glycemic control, and lifestyle factors contribute to its risk, with older adults and those with long-standing diabetes particularly vulnerable.

OBJECTIVE

To assess the prevalence and predictors of SMI in adults with diabetes, emphasizing long-term management and monitoring.

METHODOLOGY

A longitudinal observational study was conducted at Nishtar Medical University, Multan, from October 2020 to September 2022, involving 388 adults with diabetes for at least five years. Patients with significant cardiovascular diseases or recent medication-affecting biomarkers were excluded. Data collection included demographics, medical history, and clinical assessments such as HbA1c levels, 12-lead resting ECGs, and treadmill exercise stress tests, with myocardial perfusion imaging (MPI) for those unable to perform stress tests. Statistical analyses using IBM SPSS (version 22) incorporated univariate and multivariate logistic regression to identify predictors of SMI, adjusting for confounders such as age, sex, smoking, and blood pressure. Thresholds included microalbuminuria at 30-300 mg/24 hours and HbA1c ≥7%, with missing data addressed through multiple imputations.

RESULTS

Among the participants, the prevalence of SMI was 48%, increasing to 58% in those with microalbuminuria. Significant predictors included the duration of diabetes (OR 1.28, 95% CI: 1.08-1.52, p=0.001), HbA1c levels (OR 1.75, 95% CI: 1.42-2.16, p<0.001), age (OR 1.05, 95% CI: 1.01-1.09, p=0.035), and smoking status (OR 1.42, 95% CI: 1.05-1.92, p=0.025). Smoking status was based on self-report. Notably, microalbuminuria showed a strong association with SMI (OR 2.89, 95% CI: 2.10-3.98, p<0.001). The distribution of participants was balanced in terms of age and gender, with a mean age of 58 years (SD 9.4), and 52% were male. No unexpected findings were observed, and the results aligned with the anticipated relationships between the variables.

CONCLUSION

This study highlights a concerning prevalence of SMI among diabetic patients, emphasizing the importance of monitoring diabetes duration and glycemic control, particularly in individuals with microalbuminuria. Regular follow-up care, including routine ECGs, stress tests, and biomarker assessments, is crucial for improving cardiovascular outcomes in this high-risk population. Limitations such as the observational design and potential self-report bias in smoking status may affect the generalizability of the findings. Future research should focus on large-scale, multicenter studies to validate these findings and explore interventions that could reduce the burden of SMI in diabetic patients.

Disease burden and symptom management in type 2 diabetic patients: A phenomenological study

AIM

This study was conducted to address the experiences of diabetic patients from a psychosocial perspective, examine the burden of disease, and determine their practices for symptom management.

MATERIALS AND METHODS

In this study, a phenomenological research design, a qualitative research design, was used. The study included 20 diabetic patients. Individual and face-to-face interviews were performed, and Colaizzi's phenomenological analysis method was used to analyze the data.

RESULTS

As a result of the data analysis, four categories (challenges with care and treatment, coping with the disease, effects, and healthy life behaviors) and eleven main themes (knowledge, application, symptoms, support resources, spiritual coping methods, physical coping methods, physical effects, spiritual effects, social effects, physical practices, and psychological practices) emerged.

CONCLUSION

It was concluded that the disease burden of diabetic patients is intense and that the participants of the study were not effective in coping with the disease through symptom management and found spirituality important in coping.

Development and validation of the Women's Self-care Knowledge and Attitude Questionnaire (WSKAQ)

BACKGROUND

Menopausal women should learn self-care practices to enjoy a healthy lifestyle, positive health behaviors, and health status. In addition, the lack of self-care knowledge can lead to unhealthy attitudes and lifestyles, resulting in many complications. Improved self-care knowledge can foster positive attitudes, leading to healthier lifestyles as a beneficial cycle. However, menopausal women have limited knowledge about self-care and evaluation tools. Therefore, this study aimed to develop and investigate the validity and reliability of the Women's Self-care Knowledge and Attitude Questionnaire (WSKAQ) in Iranian menopausal women.

METHODS

This cross-sectional study was conducted on 249 menopausal women, aged between 45 and 65 years and at least one year post-menopause, with a minimum literacy level of elementary education. Validation properties included construct validity, exploratory (EFA), and discriminant validity. Reliability was further established through Cronbach's α and McDonald's Omega. PASS 15 and SPSS 27 software were used to select centers, calculate sample size and analyze the data, respectively.

RESULTS

The initial stage of construct validity involved the Kolmogorov-Smirnov test and EFA, resulting in a 6-item self-care knowledge subscale, 47.29% of the total data variance, and 7-item self-care attitude subscale, 55.50% of the total data variance. Independent t-test indicated that menopausal women with education level equal to or higher than diploma have significantly higher self-care attitude scores than those with lower than diploma (p = 0.007). Additionally, significant correlations were observed between self-care knowledge and attitude (r:0.30). Cronbach's α and McDonald's Omega coefficients of the 13-item WSKAQ were 0.77 and 0.78, respectively.

CONCLUSIONS

Based on the results, the WSKAQ, consisting of 13 items, was validated and reliable for assessing the self-care knowledge and attitude of Iranian menopausal women.

An exploratory study of factors in disordered eating behavior in diabetes self-management in Japan

AIMS/INTRODUCTION

Diet directly affects glucose metabolism, and eating behavior is influenced by various daily life stressors. This study was conducted to investigate the relationship between common psychosomatic stressors on endocrine hormones and eating behavior in patients with type 2 diabetes.

MATERIALS AND METHODS

This cross-sectional study was performed in 40 patients with type 2 diabetes. Resting hormone blood sampling and four self-reported questionnaires were employed.

RESULTS

Patients who scored higher on the 'anger/hostility' (AH) subcategory of the profile of mood state (POMS) questionnaire had significantly higher serum cortisol (β = 0.40, P = 0.01 by least squares adjusted for age and sex). In the eating behavior questionnaire, the subcategories of 'feeling of hunger/satiation' (β = 0.49, P < 0.01) and 'eating as diversion' (β = 0.39, P = 0.03) were associated with higher serum cortisol. Resting morning cortisol levels were higher in participants who rated high on the POMS-AH and in those who reported 'irritated when hungry' and 'tend to eat when irritated or anxious'. Sleep quality showed no association with eating behavior.

CONCLUSIONS

Mood state is associated with eating behavior. Anger increases cortisol levels and may lead to compulsive eating. Various forms of hostility are important factors in appetite control and increased cortisol secretion, and can be an impediment to successful dietary self-management in patients with type 2 diabetes. Thus, assessment of mood state and control of negative mood are important therapeutic targets in diabetes management.

Living with diabetes in Northeast India: An exploration of psychosocial factors in management

Purpose

India is the 'Diabetes Capital of the World' and accounts for one in seven adults living with diabetes worldwide. Psychosocial, economic, and cultural correlates of disease have important implications for disease management but are rarely explored in India. The purpose of this study is to address psychosocial and cultural factors in diabetes management in the northeastern region of India which has a high disease burden.

Methods

This study attempts to explore the psychosocial and lived experience of diabetes in the northeastern state of Meghalaya. The sample was selected from individuals attending an outpatient facility of a multi-speciality clinic. Semi-structured interviews were conducted with 25 individuals (13 women and 12 men), above the age of 40 years, who had been diagnosed with diabetes for at least 6 months. The narratives were analysed using thematic analysis.

Results

Using the social cognitive framework, themes were organized in terms of a thematic map linking knowledge of diabetes to the perception of diabetes as 'a silent killer', to coping, leading to self-efficacy. However high self-efficacy, over time, may lead to complacency, disrupting health behaviours and requiring re-establishment of those behaviours. Adequate knowledge along with cognitive adaptation and self-efficacy were important constructs that contributed to behaviour change and maintenance. Elements of the cultural context were observed in the spiritual aspects of adaptation, the socially isolating consequences of diabetes, as well as gender differences in social support and management.

Conclusion

Understanding the lived experiences of patients contributes to planning more effective interventions keeping the social and cultural context in mind for more effective management of diabetes. Additionally, acknowledging and supporting women's needs in diabetes management is called for.

Formulation and assessment of chickpea pulao using fenugreek seeds and Indian rennet to improve blood glycemic levels

Diabetes is becoming a significant health concern in Asia, where the prevalence has reached alarming levels. An important contributing factor is the consumption of high-carbohydrate foods, including rice, bread, etc. These high-carbohydrate foods pose a major risk to public health due to their impact on postprandial hyperglycemia. This research aimed to formulate a chickpea pulao (cooked Indian-Pakistani rice dish) and to evaluate its effects on postprandial blood glucose levels in type 2 diabetic individuals. Antioxidant potential and total phenolic contents of herbs at different concentrations (1, 3, 5, 7, and 9%) were measured through DPPH and Folin Ciocalteu assays. The antidiabetic potential was tested by α-amylase and α-glucosidase inhibition assays. After sensory evaluation, the best-chosen concentration was used to formulate the chickpea pulao. The study trial was advertised under "DP trial," and 12 participants were recruited. A single-blind randomized cross-over trial was conducted for 3 weeks with a one-week wash-over time in between. Participants' preprandial and postprandial blood glucose levels were recorded for control and intervention recipes. Results indicated that both fenugreek seeds (FS) and Indian rennet (IR) showed good antioxidant and hypoglycemic activity (p = .000) in raw and boiled extracts. For DPPH, the IC50 values of unboiled and boiled combined (FS + IR) extracts were calculated as 7.4% and 8.02%, respectively. Similarly, for α-amylase, the IC50 values of combined IR and FS unboiled and boiled extracts were 6.58% and 6.83%, and for α-glucosidase inhibition assay, the values were measured as 14.98% and 16.24%. The single-blind randomized cross-over trial showed that consuming the intervention recipe significantly reduced postprandial hyperglycemia (p = .000) in type 2 diabetic participants. The intervention recipe decreased hyperglycemia by approximately 15% daily compared to the control recipe. Incorporation of hypoglycemic herbs into dietary patterns can work as an adjunct therapy for diabetes management, especially in populations with a high prevalence of this disease.

Dietary adherence among persons with type 2 diabetes: A concurrent mixed methods study

BACKGROUND

Poor adherence to dietary recommendations among persons with type 2 diabetes (T2D) can lead to long-term complications with concomitant increases in healthcare costs and mortality rates. This study aimed to identify factors associated with dietary adherence and explore the barriers and facilitators to dietary adherence among persons with T2D.

METHODS

A concurrent mixed methods study was conducted in two hospitals in the Ashanti Region of Ghana. One hundred and forty-two (142) persons with T2D were consecutively sampled for the survey. Dietary adherence and diabetes-related nutritional knowledge (DRNK) were assessed using the Perceived Dietary Adherence Questionnaire (PDAQ) and an adapted form of the General Nutritional Knowledge Questionnaire (GNKQ-R) respectively. A purposive sample of fourteen participants was selected for interviews to explore the factors that influence dietary adherence. Qualitative data were analysed using NVivo version 20 software and presented as themes. Furthermore, binary logistic regression was performed using IBM SPSS version 29.0 to identify the factors associated with dietary adherence.

RESULTS

Nearly fifty-one percent (50.7%) of the participants in this study had good dietary adherence. In multivariable logistics regression, it was found that increase in DRNK (AOR = 1.099, 95% CI: 1.001-1.206, p = 0.041) score and living in an urban area (AOR = 3.041, 95% CI: 1.007-9.179, p = 0.047) were significantly associated with good dietary adherence. Inductive thematic analysis revealed four facilitators of dietary adherence (access to information on diet, individual food preferences and eating habits, perceived benefits of dietary adherence, and presence of social support) and four barriers (inability to afford recommended diets, barriers related to foods available in the environment, conflict between dietary recommendations and individual eating habits, and barriers related to the social environment).

CONCLUSION

The findings support the need for interventions including continuous dietary education tailored to individual preferences and dietary habits, expansion of poverty reduction social interventions and formulation of policies that will improve access to healthy foods in communities.

Cultural Influences on Making Nutritional Adjustments in Type 2 Diabetes in Pakistan: The Perspectives of People Living With Diabetes and Their Family Members

In Pakistan, type 2 diabetes is widespread, and although dietary recommendations from healthcare professionals are critical to its treatment, cultural norms can have a great influence on the dietary habits of people living with diabetes (PLwD). Understanding the social aspects of the lives of PLwD is crucial when examining the effectiveness of nutritional recommendations and adjustments. This study investigated (1) how PLwD and their family members adjust their nutrition to the recommendations of healthcare professionals to manage type 2 diabetes mellitus (T2DM) and (2) what do PLwD and their family members perceive as enablers and barriers to the necessary nutritional adjustments for managing T2DM. Prime consideration was given to experiences of living in Pakistan as the cultural context. Semi-structured interviews were conducted with 30 PLwD and 17 family members; the data were analysed thematically. Three themes emerged: (i) 'Influence of family system, gender, and age on meals prepared at home': family hierarchy and opinions based on gender and age can enable or hinder nutritional adjustment in meals prepared at home; (ii) 'Temptations of "unhealthy" foods, festivals, cultural interactions, and social etiquette': family/social interactions at home, gatherings, or festivities can affect PLwD's ability to resist temptations to eat foods prohibited by healthcare professionals; and (iii) 'Folk knowledge, folk remedy, and the balance between culture and Western medicine': PLwD and their family members in Pakistan hold strong beliefs concerning foods' medicinal properties. Power dynamics within families need to be considered when making nutritional recommendations. Medical guidelines should acknowledge personal agency and cultural beliefs.

Assessment of knowledge, attitude, and practices regarding the relationship of obesity with diabetes among the general community of Pakistan

This study sought to evaluate the influence of knowledge, attitude, and practices assessment on diabetes related to obesity in Pakistani society. Data was collected both through door to door and online survey approaches from 518 participants by using a pre-validated questionnaire. A total of 15.6% were underweight, 61.2% were normal weight, 17.2% were overweight and 5.8% were in obesity class I and 2.9% were classified as obesity class II. The co-occurrence of obesity and diabetes was 29% (n = 22) among diabetic individuals (n = 84). A majority of the residents (59.1%) were from cities. While 94% of the participants responded to what obesity was, 83.8% knew what diabetes was. Fast food, soft drinks, and mayonnaise were deemed to be healthy by 75.1% of the respondents. Obesity was viewed as a disease by 94.8%, a major health issue by 78.2%, and a weight-loss necessity by 44.6% of participants. Only 24.9% exercised every day, and 23.9% engaged in any physical activity daily. The majority of respondents (50.6%) never tried to lose weight and 23.2% ate junk food daily. The sociodemographic variables showed that the age ranges of 25-34 years (P < 0.001; OR 0.531), 45-54 years (P < 0.05; OR 0.527), and urban residency (P < 0.001; OR 0.128) had a significant association with knowledge. The factors of urban residency (P < 0.001; OR 3.996), being unmarried (P < 0.001; OR 1.95), and having an income of 51,000-70,000 (P < 0.001; OR 11.29) showed a very highly significant association with a good attitude regarding the relationship of obesity with diabetes (P < 0.05). Similarly, practices of the participants showed significant association with BMI range of 18.5-24.9 and 25-29.9 (P < 0.001). Our study revealed significant knowledge and understanding of the relationship between obesity with diabetes. However, it was observed that majority of respondents exhibited fundamental knowledge regarding obesity and diabetes, there was a notable absence of understanding regarding crucial elements, such as the significance of maintaining a healthy body weight, participating in physical activity, and implementing appropriate dietary strategies for weight control. We recognize the necessity for education initiatives and strongly encourage them to assist individuals in managing diabetes resulting from obesity.

A Study of the Use of Medicinal Plants by Persons With Type 2 Diabetes in Iran

Medicinal plants are used by many people with Type 2 diabetes in Iran. The aim of this study was to explore why this is so, from their perspective. Sixteen persons with Type 2 diabetes in Yazd City, Iran, were interviewed in April and May 2020 for this study. A thematic analysis of the transcripts of those interviews was done using MAXQDA 10 software. Six themes were identified: beliefs about medicinal plants, psychological factors, accessibility and economic barriers, patients' knowledge and awareness, social pressure, and the role of family culture. The recommendation of the study is that health counselors and specialists should provide needed information and skills for the proper use of medicinal plants, and the pharmaceutical infrastructures need to be expanded to provide enough drugs to facilitate better access to needed medication and reduce reliance on medicinal plants for persons with Type 2 diabetes.

Understanding the diabetes self-care behaviour in rural areas: Perspective of patients with type 2 diabetes mellitus and healthcare professionals

BACKGROUND

Diabetes self-care behaviour plays a crucial role in managing the diabetes effectively and preventing complications. Patients with type 2 diabetes mellitus (T2DM) and health care professionals (HCPs) of rural areas often face unique challenges when it comes to diabetes self-care practices (SCPs). Therefore, this study aim to explore the perspectives of patients with T2DM and HCPs on diabetes SCPs.

METHODS

Eight focus group discussions (FGDs) among individuals with T2DM and In-depth interviews (IDIs) with 15 HCPs were conducted in rural areas of Punjab, North India. Capability, Opportunity, Motivation, and Behaviour model (COM-B) was employed for thematic framework analyses.

RESULTS

The study participants perceived that a limited understanding of diabetes mellitus (DM), beliefs in alternative therapies, drug side effects, attitudes towards DM (psychological capability), comorbidities (physical capability), family support (social opportunity), financial and time constraints, and weather conditions (physical opportunity) contributed to lack of DM SCPs. Physicians' guidance and support were motivating them to adhere to SCPs, especially when aligned with their sense of self-efficacy (reflective motivation). HCPs constraints in providing patient-centred care are due to training limitations (psychological capability) and a lack of essential resources (physical opportunities). Participants expressed need for comprehensive diabetes care (automatic motivation) through structured diabetes education intervention to improve diabetes SCPs.

CONCLUSIONS

The study findings indicate that various factors influence diabetes SCPs from the perspectives of both patients with T2DM and HCPs and emphasizes the need for a multi-faceted approach to improve diabetes SCPs in rural areas. Implementing a structured diabetes self-care intervention strategy in rural areas may help for preventing and mitigating the impact of diabetes-related complications in rural areas.

Factors Influencing Medication Adherence Among Adults Living with Diabetes and Comorbidities: a Qualitative Systematic Review

PURPOSE OF REVIEW

Medication adherence plays an important role in improving health outcomes related to diabetes and comorbidity. The potential factors influencing medication adherence and how they contribute to health behaviors have not been synthesized to date. This review synthesized qualitative studies that identified factors influencing medication adherence among adults living with diabetes and comorbidity.

RECENT FINDINGS

Twenty-eight findings were extracted and synthesized into four themes: perceived support, lack of knowledge, medication issues, and the importance of routine. The findings highlight the factors that support medication adherence and areas that can be targeted to support and promote medication adherence. The findings also support the potential role of healthcare providers in supporting people living with diabetes and comorbidity to adhere to and maintain medication regimes. Several factors were identified that are amenable to intervention within the clinical practice setting and have the potential to enhance medication adherence and improve health outcomes for people living with diabetes and comorbidities. The development of acceptable and effective interventions could have a positive effect on medication adherence and health outcomes.

Self-management of chronic, non-communicable diseases in South Asian settings: A systematic mixed-studies review

Self-management is crucial in mitigating the impacts of a growing non-communicable disease (NCD) burden, particularly in Low and Middle-Income countries. What influences self-management in these settings, however, is poorly understood. We aimed to identify the determinants of self-management in the high NCD region of South Asia and explore how they influence self-management. A systematic mixed-studies review was conducted. Key electronic databases [MEDLINE (1946+), Embase (1974+), PsycInfo (1967+) and CINAHL (EBSCOhost)] in March 2022 (and updated in April 2023) were searched for studies on the self-management of four high-burden NCD groups: cardiovascular diseases, type 2 diabetes, chronic respiratory diseases and depression. Study characteristics and quantitative data were extracted using a structured template, and qualitative information was extracted using NVivo. Quality appraisal was done using the Mixed Methods Assessment Tool (MMAT). Quantitative findings were organised using the Commission on Social Determinants of Health (CSDH) framework and synthesised narratively, supported by effect direction plots. Qualitative findings were thematically synthesised. Both were integrated in a mixed synthesis. Forty-four studies (26 quantitative, 16 qualitative and 2 mixed-methods studies) were included, the majority of which were conducted in urban settings and among individuals with diabetes and cardiovascular diseases. Higher age, education, and income (structural determinants), health-related knowledge, social support and self-efficacy (psychosocial determinants), longer illness duration and physical comorbidity (biologic determinants), and the affordability of medicine (health-system determinants) were key determinants of self-management. Qualitative themes highlighted the role of financial adversity and the social and physical environment in shaping self-management.A complex interplay of structural and intermediary social determinants shapes self-management in South Asian settings. Multi-component, whole-systems approaches could boost self-management in these settings. Key areas include empowerment and education of patients and wider community, design and delivery of bespoke behavioural interventions and a stronger emphasis on supporting self-management in healthcare settings.

Psychosocial Facilitators and Barriers to Type 2 Diabetes Management in Adults: A Meta-Synthesis

BACKGROUND

Globally, the cases of type 2 diabetes are increasing, and this is largely attributed to lifestyle changes. Though diabetes is primarily a metabolic disease determined by biological factors, psychosocial aspects play a crucial role in its progression and management. However, the literature on psychosocial dimensions of diabetes management is minuscule and scattered.

OBJECTIVE

This synthesis sought to understand the psychosocial facilitators and barriers to type 2 diabetes management and coping among adults.

METHODS

We have adopted a meta-synthesis to review available qualitative studies using Pub- Med and Scopus databases. Based on inclusion criteria, we have chosen 24 studies published between 2010 and 2023. We have considered studies across countries, among which 63% of the studies included were from Western countries, and most have employed qualitative descriptive design. The selected studies were analyzed thematically using a deductive framework.

RESULTS

Six themes emerged as the psychosocial barriers and facilitators of managing and coping with type 2 diabetes: 1) cognitive-emotional factors, 2) faith, 3) constraints to behavioural change, 4) social constraints and support, 5) healthcare provider-patient relationship, and 6) awareness. Further, a conceptual framework was developed from the synthesis.

CONCLUSION

The patients' experiences evident from this synthesis signify the crucial role of psychosocial factors in diabetes management and coping. This evidence emphasizes the need for integrated care so that psychosocial aspects are addressed by healthcare providers and behavioural health professionals, which may lead to the promotion of facilitators and the minimization of barriers.

Lived experience of diet-related health education in type 2 diabetes and hypertension comorbidity in The Gambia

The incidence and prevalence of type 2 diabetes mellitus (T2DM) and hypertension (and their comorbidity) have been increasing in sub-Saharan Africa, including The Gambia. Diet is a critical driver of these public health problems, and diet-related health education is a major strategy employed for their prevention and management. The aim of this paper is to explore the lived experiences of diet-related health education among individuals with comorbid type 2 diabetes and hypertension in Serrekunda, The Gambia, a subject hitherto unexplored in the country. The study employed a qualitative (interpretivist) methodology. Thirty-two interviews were conducted with 18 participants, with most participating in two interviews at separate time-points between November 2018 and July 2019. In addition to participant validation, the two points in time interviews elicited more depth and provided rich data. The data were analysed using Braun and Clarke's six-phased approach to Thematic Analysis. Four main themes were generated in relation to the experiences: (i) one-off blanket dietary advice (ii) education in a vacuum (iii) diabetes-hypertension diet dichotomy and (iv) imbalanced power relationship. The study underscores the need for a reconfiguration of diet-related health education in The Gambia to include lived experiences as critical components of health promotion in tackling T2DM and hypertension. This requires an ecological approach, critical health education, regulations on unhealthy foods, and active participation of individuals as equal partners in health education.

Self-Reported Dietary Management Behaviors and Dietary Intake among Chinese Adults with Diabetes: A Population-Based Study

Few studies have analyzed the implementation of dietary management in Chinese adults with diabetes. Thus, we assessed and compared dietary intake and diet quality between diabetic patients with and without dietary management behaviors (DPDM vs. NDPDM), and evaluated the adherence to dietary guidelines in both groups of patients. The data were obtained from the 2002, 2010-2013, and 2015 China National Nutrition Survey. A total of 69,583, 67,177, and 96,631 subjects participated in the 2002, 2010-2013, and 2015 survey rounds, respectively. The dietary intake data were measured using 3-day 24 h dietary recalls and weighed records of household condiments. The China Healthy Diet Index (CHDI) was used to evaluate diet quality. The study included 6229 patients with diabetes, of which 78% had dietary management behaviors. The diabetic patients with dietary management behaviors showed higher percentages of energy from high-quality carbohydrates, animal protein, saturated fatty acids, and unsaturated fatty acids and lower percentages from low-quality carbohydrates and plant protein than NDPDM. The diabetic patients with dietary management behaviors also had lower intakes of cereals and tubers and higher intakes of vegetables than NDPDM. The total CHDI score of DPDM was higher than NDPDM (56.3 ± 12.7 vs. 54.1 ± 12.3). The proportion of DPDM meeting the recommended intake for different food items ranged from 3.3% to 42.8% and from 3.0% to 39.2% in NDPDM. The diabetic patients with dietary management behaviors showed better adherence to dietary guidelines and higher diet quality scores than NDPDM, while the overall adherence was poor in both groups of patients. Our findings suggested that measures are needed to promote and refine dietary management behaviors, which can help to improve disease management in diabetic patients.

Psychological Predictors of Adherence to Self-Care Behaviour amongst Patients with Type 2 Diabetes Mellitus (T2DM) Visiting Public Hospital, North India

Background and Aims

Patients with type 2 diabetes mellitus (T2DM) need a high degree of self-care behavior, treatment adherence, and good psychological health. Psychological health play a vital role in adherence to treatment regimen and self-management of diabetes. This study aims to identify the psychological predictors of self-care behaviors among patients with T2DM.

Methods

A descriptive cross-sectional survey was conducted at a diabetic clinic at a tertiary care hospital in North India. Structured pre-tested personal and clinical profile and self-efficacy, diabetes distress, depression and anxiety, and complications and fear of developing hypoglycaemia due to diabetes mellitus in the future are measured through standardized questionnaires.

Results

The mean age of the participants was 53.5 (±3.68) years, and 41.4% were in the overweight (BMI: 25.0-29.9) and obese (16.7%, BMI > 30) category. Self-care behaviours found significant association with self-efficacy (r = 0.34, P < 0.001), anxiety (r = -0.28, P < 0.001), depression (r = -0.28, P < 0.001) and diabetes-related distress (r = -0.30, P < 0.001). Further, self-efficacy (P = 0.001), diabetes distress (P < 0.001) and fear of developing hypoglycaemia (P < 0.001) were reported independent predictors of self-care behaviour in patients with T2DM.

Conclusions

The current study suggests that self-efficacy, fear of hypoglycaemia and emotional state played an important role in adherence to self-care behaviour in T2DM management. Patients with diabetes mellitus should be routinely screened for psychological factors at diabetes clinics. Thus, developing tailored interventions to raise belief and self-efficacy might be a useful way to increase the involvement of patients in treatment.

Successful Practices in Performing and Maintaining Physical Activity in Adults with Type 2 Diabetes Mellitus: A Qualitative Study

Physical activity has proven to be greatly beneficial in patients with DM2. However, few adhere to physical activity recommendations and are motivated to engage in regular physical activity and the numerous interventions conducted to change their habits tend to be unsuccessful in the long term. The objective in this research is to study patients who adhere to physical activity in order to guide patients who have not succeeded in making this change, assisted by the successful tools in the context of community nursing. A qualitative descriptive study was conducted. The sample included 10 patients with type 2 diabetes mellitus who adhered to physical activity in Catalonia, Spain, having been selected using intentional sampling. We recorded semi-structured interviews with the participants and conducted a thematic analysis. Five categories were identified and grouped into two themes: (1) Integrate physical activity as a lifestyle (meaning of DM2 and physical activity, adaptation to change and strategies on a day-to-day basis, physical activity) and (2) Find support to change physical activity (company and personal motivational strategies). In conclusion, a good adherence to physical activity was achieved thanks to motivation maintained over time related to autonomous motivation and the psychological and physiological benefits that physical activity provides patients, external support and encouragement, and the allocation of time to adhere without making great lifestyle changes.

Undertaking Healthy Nutrition Behaviors by Patients with Type 1 Diabetes as an Important Element of Self-Care

BACKGROUND

Self-control/self-care means the active participation of a diabetic patient in therapy. It involves making numerous decisions and undertaking actions independently. The primary activities under the patient's control include adherence to medication regimens and maintenance of a health-promoting lifestyle, especially a healthy diet. However, the sense of responsibility for one's own health, i.e., high sense of responsibility (HSR), is an important element in the treatment of diabetes and in undertaking pro-health behaviors. The study aimed at analyzing adherence to dietary recommendations in the context of HSR in patients with type 1 diabetes.

METHODS

The cross-sectional study was conducted on a group of 394 adults. The assessment of adherence to dietary recommendations was performed with the present authors' Diabetes Dietary Guidelines Adherence Index (DDGA Index). The measurement of HSR was performed with the standardized Sense of Responsibility for Health Scale (HSRS). The assessment of the multifactorial influence of independent variables on the DDGA Index, including the "responsibility for health" variable, was conducted with the use of a linear regression model.

RESULTS

The mean DDGA value was 18.68 (SD = 3.97). The patients significantly more often avoided unhealthy products than included recommended products into the diet at a required frequency. A positive correlation was demonstrated between HSR and adherence to dietary recommendations (β_std. = 0.43, p < 0.001).

CONCLUSIONS

The sense of responsibility for one's health plays a main role in adherence to dietary recommendations in diabetes. Our study showed that a higher sense of responsibility for health was associated with a higher level of adherence to dietary recommendations. Patients with a high sense of responsibility for one's health will be more involved in the therapeutic process, including adherence to dietary recommendations. Therefore, all education actions should comprise not only dietary knowledge transfer and shaping appropriate skills, but they should also strengthen the sense of responsibility for one's health.

A Qualitative Exploration of Self-Management Behaviors and Influencing Factors in Patients With Type 2 Diabetes

BACKGROUND AND AIMS

The self-management behavior of patients with diabetes involves a complex set of actions involving medication therapy, lifestyle changes, and management of complications in the daily routine. Our study aims to explore adherence to self-management behaviors by patients with type 2 diabetes and the potential factors influencing those behaviors.

METHODS

This qualitative study used semi-structured interviews conducted with patients who have type 2 diabetes and who were recruited from the department of endocrinology in a tertiary teaching hospital. Data were analyzed thematically using the interview framework.

RESULTS

Overall, 28 patients with type 2 diabetes were recruited and interviewed. Three types of medication noncompliance behaviors were coded. In particular, blindly optimistic attitudes toward the condition in younger patients who had a short duration of diabetes and fear of or pain from medication therapy were key influencing factors. Irregular monitoring and missed follow-up visits were the most frequently mentioned noncompliance behaviors. Poor understanding of blood glucose monitoring, selective ignorance due to pressure of uncontrolled blood glucose, and blindly optimistic attitudes were also identified as key influencing factors. Dietary behaviors were characterized by an overemphasis on the amount of food in the diet and the preference or declination for particular types of food; ignorance of the dietary structure was present. Misconceptions about dietary and exercise practices were the main types of lifestyles' noncompliance.

CONCLUSION

Our study showed the complex picture of noncompliance with self-management behaviors by patients with type 2 diabetes. Noncompliance covered disordered and arbitrary changes in medication therapy, blood glucose monitoring with poorest adherence, lifestyle modifications and complication management. The study findings identify clear challenges to self-management behavior and identify potential key influencing factors. Future interventions and strategies should aim to help patients translate healthcare provider's information and instructions into action that improve compliance.

Self-Care in Patients with Non-Optimal Diabetes Management in Brazilian Rural Areas: A Mixed-Methods Study

PURPOSE

This study aims to assess self-care in patients with non-optimal diabetes management (HbA1c >7.0% for adults and >8.0 for those aged 60 or over) and the positive and negative experiences associated with it in the rural communities of a Brazilian municipality.

PATIENT AND METHODS

This is a cross-sectional mixed-methods study. The data were collected from participants with high HbA1c through focus group discussions, subsequently performing thematic analysis, and through structured questionnaires (socioeconomic characteristics and the Summary of Diabetes Self-Care Activities (SDSCA)).

RESULTS

The mean HbA1c of the 156 study participants was 9.94% (95% confidence interval: 9.70-10.19%) and most participants (86.54%) had negative self-care behaviors, with an overall SDSCA mean score of 3.55. This mean was not positive for any of the socioeconomic characteristics. The self-care activities with the most satisfactory performance concerned non-smoking and the use of prescribed medications, and the poorest results were observed for the practice of specific physical activities. The qualitative data indicated that the study participants face many difficulties regarding self-care practices, especially those related to an adequate diet.

CONCLUSION

The self-care assessment revealed unsatisfactory self-care behaviors as well as high HbA1c levels among the study participants and highlighted the various difficulties they encounter. This indicates the need for more attentive health teams to monitor patients, especially regarding actions focused on the non-pharmacological elements of self-care, such as lifestyle changes, which were found to be the dimensions with the most unsatisfactory results.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Emotional distress, anxiety and depression in South Asians with long-term conditions: a qualitative systematic review

Background

People with physical–mental comorbidity have a poorer quality of life, worse clinical outcomes, and increased mortality compared with people with physical conditions alone. People of South Asian (SA) origin are the largest minority group in the UK and are more likely to have long-term conditions (LTCs) such as diabetes and heart disease. People of SA origin are less likely to recognise symptoms that may represent mental health problems.

Aim

To explore how people of SA origin with LTCs understand, experience, and seek help for emotional distress, depression, and anxiety.

Design and setting

Systematic review of qualitative studies exploring emotional distress in people of SA origin with diabetes or coronary heart disease, within primary and community care settings worldwide.

Method

Comprehensive searches of eight electronic databases from inception to 1 September 2021 were undertaken. Data extracted included study characteristics, and understanding, experience, and help-seeking behaviour for emotional distress. Thematic synthesis was undertaken. The Critical Appraisal Skills Programme (CASP) checklist for qualitative studies was used to assess quality of articles, and Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) used to determine the overall strength of evidence.

Results

Twenty-one studies from 3165 unique citations were included. Three main themes were identified. Understanding of emotional distress: non-medical terminology used, such as ‘tension’, and a complex relationship between emotional and physical illness. Experiences of emotional distress: multiple forms of inequality, distress at diagnosis of their LTC, cultural factors, and sex differences. Help-seeking behaviour: self-management, support from family, friends, and faith, and inadequate clinical support.

Conclusion

This review provides a greater understanding of the conceptualisation of emotional distress in the context of LTCs by people of SA origin, to support improvement in its recognition and management.

Diabetes and conversational agents: the AIDA project case study

One of the key aspects in the process of caring for people with diabetes is Therapeutic Education (TE). TE is a teaching process for training patients so that they can self-manage their care plan. Alongside traditional methods of providing educational content, there are now alternative forms of delivery thanks to the implementation of advanced Information Technologies systems such as conversational agents (CAs). In this context, we present the AIDA project: an ensemble of two different CAs intended to provide a TE tool for people with diabetes. The Artificial Intelligence Diabetes Assistant (AIDA) consists of a text-based chatbot and a speech-based dialog system. Their content has been created and validated by a scientific board. AIDA Chatbot—the text-based agent—provides a broad spectrum of information about diabetes, while AIDA Cookbot—the voice-based agent—presents recipes compliant with a diabetic patient’s diet. We provide a thorough description of the development process for both agents, the technology employed and their usage by the general public. AIDA Chatbot and AIDA Cookbot are freely available and they represent the first example of conversational agents in Italian to support diabetes patients, clinicians and caregivers.

Developing a Complex Understanding of Physical Activity in Cardiometabolic Disease from Low-to-Middle-Income Countries-A Qualitative Systematic Review with Meta-Synthesis

Physical activity behaviour is complex, particularly in low-resource settings, while existing behavioural models of physical activity behaviour are often linear and deterministic. The objective of this review was to (i) synthesise the wide scope of factors that affect physical activity and thereby (ii) underpin the complexity of physical activity in low-resource settings through a qualitative meta-synthesis of studies conducted among patients with cardiometabolic disease living in low-to-middle income countries (LMIC). A total of 41 studies were included from 1200 unique citations (up to 15 March 2021). Using a hybrid form of content analysis, unique factors (n = 208) that inform physical activity were identified, and, through qualitative meta-synthesis, these codes were aggregated into categories (n = 61) and synthesised findings (n = 26). An additional five findings were added through deliberation within the review team. Collectively, the 31 synthesised findings highlight the complexity of physical activity behaviour, and the connectedness between person, social context, healthcare system, and built and natural environment. Existing behavioural and ecological models are inadequate in fully understanding physical activity participation in patients with cardiometabolic disease living in LMIC. Future research, building on complexity science and systems thinking, is needed to identify key mechanisms of action applicable to the local context.