1. EGPRN
ATard
,
Malta
2013
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

2. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Implica;ons
Diabetes
Mellitus
-­‐
Prevalence
-­‐
6.4%¹
(2010)
7.7%¹
(2030)
6.5%
²
(2006)
11.7%
³
(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.

3. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Implica;ons
Diabetes
Mellitus
-­‐
Importance
in
Portugal
-­‐

Portugal
(2008)¹
•
0.7%
of
the
GDP
•
7%
of
total
health
expenditure

50%
of
Portuguese
diabe;cs
do
not
reach
metabolic
control²
2)
1)
Diabetes:
factos
e
números,
2009.
Relatório
anual
do
Observatório
Nacional
da
Diabetes.
Observatório
Nacional
da
Diabetes,
2009
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

4. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Pa4ent
factors:
• Age
• Gender
• Level
of
educa;on
• Socio-­‐economic
level
• Health
literacy
• Digital
literacy
• Lifestyle
• Social
support
• Co-­‐morbidi;es
• Weight
and
BMI
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
Results
LDLc
Blood
pressure
Metabolic
control
Discussion
Implica;ons
Adherence
to
medica4on
Disease-­‐related
factors:
•
DM
dura;on
•
Treatment
(side
effects,
regimen
burden...)
Self-­‐management
Diabetes
symptoms
Process
of
care:
• Consulta;ons
• Health
informa;on
and
advice
• Treatment
(side
effects,
regimen
burden...)

5. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Pa4ent
factors:
• Age
• Gender
• Level
of
educa;on
• Socio-­‐economic
level
• Health
literacy
• Digital
literacy
• Lifestyle
• Social
support
• Co-­‐morbidi;es
• Weight
and
BMI
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
Results
LDLc
Blood
pressure
Metabolic
control
Discussion
Implica;ons
Adherence
to
medica4on
Disease-­‐related
factors:
•
DM
dura;on
•
Treatment
(side
effects,
regimen
burden...)
Self-­‐management
Diabetes
symptoms
Process
of
care:
• Consulta;ons
• Health
informa;on
and
advice
• Treatment
(side
effects,
regimen
burden...)

6. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
1
hour/year
with
the
physician
8700
hours/year
of
self-­‐management
Mohammad
Al-­‐Ubaydli.
Personal
Health
Rcords:
a
guide
to
clinicians.
Wiley-­‐Blacwell
Implica;ons

7. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Implica;ons
Effect
on
HbA1c
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

8. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Implica;ons
Research
ques4on
What
are
the
facilitators,
barriers
and
needs
in
the
self-­‐
management
of
type
2
diabetes
(perceived
by
pa;ents)?

9. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
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
Implica;ons

10. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Interview
guide
Discussion
Implica;ons

11. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
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
Discussion
Implica;ons

12. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Implica;ons

13. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Barriers
Facilitators
and
needs
Diet
Physical
exercise
Glycemic
control
Knowledge
/
informa;on
Family
and
social
aspects
Implica;ons

14. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Barriers
Facilitators
and
needs
Diet
Physical
exercise
Glycemic
control
Knowledge
/
informa;on
Family
and
social
aspects
Implica;ons

15. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Implica;ons
Barriers
Diet
Quality
€
€
Cravings
Quan;ty
Specific
recipes
Schedule
Intrinsic
Por;on
size
Rigid
meal
schedule
Mo;va;on
Knowledge
/
informa;on
(confusion,
myths,
lack
of
specific
knowledge)
Family
and
social
aspects
(holidays,
social
events,
cooking
for
others)

16. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Implica;ons
“My
biggest
struggle
is
the
diet
because
I
enjoy
ea;ng.”
“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.”
“I
think
that
the
biggest
problem
is
not
having
the
mo;va;on
to
have
a
healthy
diet.”

17. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Barriers
Facilitators
and
needs
Diet
Physical
exercise
Glycemic
control
Knowledge
/
informa;on
Family
and
social
aspects
Implica;ons

18. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Implica;ons
Barriers
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)

19. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Implica;ons
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.”

20. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Barriers
Facilitators
and
needs
Diet
Physical
exercise
Glycemic
control
Knowledge
/
informa;on
Family
and
social
aspects
Implica;ons

21. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Implica;ons
Barriers
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)

22. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Barriers
Facilitators
and
needs
Diet
Physical
exercise
Glycemic
control
Knowledge
/
informa;on
Family
and
social
aspects
Implica;ons

23. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Implica;ons
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

24. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Implica;ons
Facilitators
and
needs
(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.”
“There
is
not
enough
informa;on
–
there
should
be
more,
is
a
disease
that
affects
so
many
people.”

25. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
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.

26. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
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)
3)
4)
5)
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
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
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
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

27. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
Limita4ons
• Generalizability
• Number
of
par;cipants
• Number
of
focus
groups
/
satura;on
• Context
-­‐
usual
place
of
care
(ability
to
speak
freely?)
Implica;ons

28. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
Background
Methods
Results
Discussion
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

29. Facilitators,
barriers
and
needs
in
the
self-­‐management
of
type
2
diabetes
liliana.laranjo@gmail.com
@LilianaLaranjo