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

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

  1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 10. Facilitators,  barriers  and  needs  in  the  self-­‐management  of  type  2  diabetes     Background   Methods   Results   Interview  guide   Discussion   Implica;ons  
  11. 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. 12. Facilitators,  barriers  and  needs  in  the  self-­‐management  of  type  2  diabetes     Background   Methods   Results   Discussion   Implica;ons  
  13. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 29. Facilitators,  barriers  and  needs  in  the  self-­‐management  of  type  2  diabetes        liliana.laranjo@gmail.com            @LilianaLaranjo  

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