Barrier to the self-management of type 2 diabetes in elderly people

This assignment explores the barrier to the self-management of type 2 diabetes in elderly people. It discusses the experiences of self-management and the role of education and knowledge in supporting self-management. The study uses qualitative methodology and thematic analysis to gather insights from selected articles.

Academic and Practice
Enquiry
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Contents
TITLE: “Barrier to the self-management of type 2 diabetes in elderly people”........................3
Introduction................................................................................................................................3
Methodology..............................................................................................................................4
Results........................................................................................................................................8
Theme 1: Experiences of self-management of type two diabetes..........................................8
Theme 2: Gaining education and knowledge supports the self-management of type two
diabetes.................................................................................................................................11
Implementation of findings......................................................................................................14
Conclusions..............................................................................................................................15
References................................................................................................................................15
APPENDIX..............................................................................................................................22
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TITLE: “Barrier to the self-management of type 2 diabetes in elderly people”
Introduction
Diabetes mellitus is referred as the metabolic disease which causes high level of blood
sugar. The insulin hormone move sugar from blood into cells to be stored or utilised for
energy. The untreated high level of blood sugar can damage the kidneys, eyes, nerves and
other organs of body. Being overweight increases the risk of diabetes as it makes the cells
more resistant to insulin effects on blood sugar.
The following assignment is based on the barrier to the self-management of type 2
diabetes in elderly people. Diabetes mellitus is an adverse health concern within global
healthcare settings (Tangvarasittichai , 2015) .There are two types of diabetes mellitus for the
purpose of this assignment type 2 diabetes (T2D) will be referenced.
The disease is experienced by patients with a lack of potency to use or produce insulin
effectively (Tangvarasittichai, 2015). Globally, diabetes is the most prevalent disease evident
from the reporting of 425 million adults in 2017, which is projected to increase to 629 million
by 2045 (Ogurtsova et al., 2017 : WHO, 2018).Centres for Disease Control and Prevention
(2014) has highlighted that, serious complications emerge if diabetes mellitus is not
adequately controlled resulting in outcomes such as cerebrovascular disease, kidney failure,
coronary heart diseases, as well as neuropathy diseases. To minimise complications and poor
management individual must possess adequate knowledge needed for effective management
of their diabetes(Young-Hyman et al,2016). Azreena et al. (2016) also demonstrated that
there are several factors which impact the patient’s knowledge about diabetes outcomes, for
this reason this has inspired me to select this topic in order to raise further health
consciousness of the implications it could left on a person, if untreated due to lack of
information or care being given to elderly people with T2D.
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This project is based on the title "Barrier to the self-management of type 2 diabetes in
elderly people". The main reason behind choosing this topic for literature review is that it
assists in gaining deep knowledge on the topic by performing in depth research. It helps in
getting information and knowledge about the experiences of self-management of type 2
diabetes along with the education and knowledge that supports its self-management. This
assists researcher in determining the barrier that may occur in self-management of type 2
diabetes. This study not only support the researcher in enhancing the knowledge, but the
research has academic importance also. This study act as a base for other scholars to perform
further research on the topic.
An integrative literature review is essential for this study, as it helps in widening the
understanding surrounding the answers to the chosen research question; it is also essential for
healthcare workers to identify the gaps during patient assessments and when making
treatment recommendation based on evidenced-based research (Torraco, 2016).
Methodology
Literature reviews are important as they help to identify dated concepts on diverse
literature topics by providing debates finding on different theories (Snyder, 2019; 2016).
Literature reviews also help to identify evidence-based practice (EBP), which is defined as
clinical core skills that teach a healthcare professional the knowledge they should acquire or
gain from research (Tavares de Souza et al., 2010). EBP uses literature review as a form of
research knowledge in enhance knowledge decisions concerning patient care . A qualitative
methodology was used for this review because; it explains the observations of the study and
helps to develop concepts or hypotheses for potential quantitative analysis (Miller, 2011).
Qualitative analysis helps to discover trends in thought and opinions and dive deeper into the
problem (Miller, 2011). Qualitative research is reflexive, meaning that the research process is
determined by the researcher's own values, experiences, and interests (Qu and Dumay,
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2011).This was particularly useful in answering my research question ,as it seeks to
understand patient experience in order to determine barriers faced with T2D. One of the
advantages of qualitative research is allows researchers to compare finding with previous
research around same topic and determine level of transferability (Tong and dew,2016).
However a disadvantage to qualitative research is the difficult in replicating research to the
same degree of certainty that quantitative research allows, this due to small sample size
(Atieno,2009).
Several electronic databases searched was used for this literature review which includes;
BMC, PubMed, CINAHL, Google Scholar, Science-Direct, and Medline, as these were
appropriate nursing databases that provide evidence-based literature relevant for this subject
(Wright et al., 2015). In order to attain an additional number of articles, the Snowballing
technique was utilised (Duraman et al , 2015) in which the list of references of the acquired
research articles is utilised for identifying more articles (Refer to Table 1 below).
Table 1: Databases Used for this Research
BMC Nursing BMC Nursing is an open-access peer-
reviewed nursing journal which is published
by BioMed Central and covers all of the
aspects of nursing training, research,
practice and education (BMC Nursing,
2020).
PubMed PubMed is a free database of NIH (National
Library of Medicine) that provides support
in the search and acquisition of literature
related to biomedical and life sciences (NIH,
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2020).
CINAHL CINAHL is regarded as the most
comprehensive database for nursing and
allied health journals (EBSCO, 2020).
ScienceDirect ScienceDirect is the peer-reviewed scholarly
literature platform of Elsevier
(ScienceDirect, 2020).
Google Scholar Google Scholar is a web search engine that
can be accessed freely and have metadata or
full-text scholarly articles throughout an
array of disciplines (Zientek, et al., 2018).
Population, Exposure, Outcome (PEO), is a well-known, recognised formula which
helps in identifying interventions, problems and outcome (Fawcett, 2016). It allows
researchers to search for the evidence to produce an appropriate literature review within the
context (Fawcett, 2016). The use of PEO in this review is illustrated in Table 2 below
Table 2: Matching review question to PEO
P (Population) Elderly people with Type 2 Diabetes? age
range (65-74)
E (Exposure) Diagnosed with Type 2 Diabetes
O (Outcomes) Improving self-management of diabetes
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The keywords used for searching the relevant literature includes: ‘Type 2 Diabetes’,
‘Elderly People’, ‘Self-management’, and ‘Barriers’. Moreover, the searches generated about
230 qualitative articles, after the application of certain exclusion criteria, the number reduced
to 60 articles, which among them the most eight (8) relevant ones where were selected for
further review purpose. Also, to filter research articles a ‘AND , ‘OR’ was used to help
narrow down research to be more specific to research question. (Garg,2016).
An inclusion and exclusion criteria were applied to identify the content needed to
address the research question giving the optimum outcome and avoiding any deviation by
averting articles that do not meet the criteria (Gosall and Gosall,2012).
Two themes emerged from the data extraction which were Gaining education and
knowledge supports the self-management of type two diabetes and Experiences of self-
management of type two diabetes (see appendix table 2 and 3).
Table 3: Inclusion and Exclusion Criteria
Inclusion Criteria Exclusion Criteria
Primary research article Secondary research articles
Published in the English language Research samples consisted of children with
Type 2 Diabetes.
Published within the last ten years Research where participants primarily lived
with other illness than Type 2 Diabetes.
Qualitative research article:
phenomenological, grounded theory,
Quantitative studies
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descriptive, ethnography
Full text articles Letters
Commentaries
Reviews
Discussion papers
Involved patients living with Type 2 Diabetes. Newly diagnosed patients
Research samples consisted of adults of
working age only
I initially excluded non -UK Research,
however due to lack of UK based studies with
was amended to include research as there
more in-depth research from other countries
Research investigated lived experiences of
service users in the workplace or labour
market
Research on Type 1 diabetes
Research Question: What are the barriers to the self-management of type 2 diabetes
in elderly people in the UK?
Results
There are two main themes of study which are emerged from 8 selected articles.
These themes include: "experiences of self-management of type 2 diabetes" and "ginning
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education and knowledge that supports the self-management of type 2 diabetes". The results
from the study from selected articles are discussed below:
Theme 1: Experiences of self-management of type two diabetes
Ehab Mudher Mikhael and et. al., (2019), performed the study and adopted a
qualitative based research framework which was used to acquire the data from type 2 diabetes
mellitus patients from National Diabetes Centre. The data was collected by using semi
structured interview method and the data was processed by using thematic analysis approach.
In the study, face to face interview was carry out with the patient suffering from type 2
diabetes in order to get deep understanding of patients about diabetes, its associated
complications as well as self-management of diabetes. Besides, the study explores self-
management behaviour of patient and their opinions and views towards diabetes self-
management educational program. The interview questions developed in the study were open
ended and was developed through reviewing relevant literature as well as validated through
group of experts in the area of diabetes management.
Total 25 in depth interviews were performed with type 2 diabetes mellitus patients. 4
themes are studied in the study including general knowledge regarding diabetes and its
complications, its self-management, barriers for diabetes self-management practices and
diabetes self-management education program. It has been found from the study that diabetes
is chronic disease and require long-term treatment for rest of the life. It is similar to cancer
because it can destroy the other organs of body. Apart from this, it has been found that there
are several complications associated with diabetes including renal failure, visual issues, heart
disease, neuropathy, stroke, diabetic foot problems and sexual dysfunction. In addition to
this, most of the participants of a study determined that physical activity, healthy diet, regular
monitoring of blood glucose, regular use of antidiabetic medications, daily foot care, regular
physician visits and healthy coping with stress are the main components of self-management
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practices of diabetes which can help people in controlling level of blood glucose in the body
and prevent from complications associated with diabetes. Moreover, the participants in the
study were able to define the diabetes correctly a serious chronic disease. The participants
said that lack of adherence to healthy patterns of eating can outcomes into hyperglycaemia.
Most of the respondents in the study suffering from diabetes complications and considered
renal failure and blindness as frightening diabetes complication. It has been found from this
study that most of the participants are aware of significance of self-management behaviours
in order to control and prevents the complications associated with diabetes. However, the key
limitation of the study involving that the sample was taken only from one diabetes centre in
Baghdad. Thus, in order to confirm the results of study, large study sample from district
diabetes centres at district Iraqi governorates is required.
O’Brien et al., (2015) adopted a qualitative framework for this study to explore
participant’s thoughts, opinions, and feelings. The research study performed by O’Brien et
al., (2015), explores the experiences of individuals with type 2 diabetes related to self-
management. The research was exploratory in nature and contextual framework was used for
the study. Purpose of sampling method was utilised to choose individuals living with type 2
diabetes mellitus from public and private healthcare facilities. Semi structured interviews
were utilised to collect data and for analysis and coding, Tesch's method of thematic analysis
was used. By addressing the constructs of credibility, dependability, transferability and
confirmability, the trustworthiness of study was make sure which is the key strength of study.
Apart from this, ethical considerations are considered while performing research which is the
another strength of study. It has been found from the study that the individuals living with
type 2 diabetes experience various challenges along the road to accomplish optimal self-
management of diabetes. The challenges range from emotional problems to practical
considerations in order to enhance the status of health. The study depicts that individuals
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generally are positive regarding their health and don't realise that there is a link between their
current behaviour and development of chronic condition later in life. Participants in the study
said that when people experience deep understanding of requirement and reasons for change,
it became easy to execute lifestyle changes about medication, exercise and diet. all the
participants of study acknowledge significance of self-discipline in accomplishing optimal
self-management. However, the study was limited to individuals living in Nelson Mandela
bay Suburban and urban area which was the limitation of study. Apart from this, the
participants of study were not insulin-dependent as it emphasized on individuals living with
type 2 diabetes.
The researcher utilised semi structured interviews in which 19 participants were
interviewed within the privacy of patient homes. Unstructured interviews, which use public
surveys to generate qualitative data; this method allows respondents to discuss in detail and
write own wording , explore participants own feeling and thoughts on a particular subject
and collect open ended data (Qu and Dumay, 2011).However a downfall to semi structured
interviews is that it is difficult to ascertain whether participants are being truthful with
questions being asked, (Dejonckheere and Vaughn ,2019).
According to the study performed by Carolan et al., (2014), it aims to explore the
concerns and experiences of individual with type 2 diabetes, in predominantly social
economic setting. The authors used exploratory qualitative design in the study and focus
groups were utilised collecting the data from 22 individuals who are aged 40 to over 70 years.
In the study, participants were described their experience is associated with managing their
diabetes as physically, socially and emotionally challenging. 4 main themes were revealed in
the study involving personal journey, diabetes the silent disease, work of managing diabetes
and access to services and resources. Findings from the study reveals numerous unmet
information as well as support requirements for people with type 2 diabetes. The participants
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in the study were satisfied with their care for diabetes but determine the need for simple
instruction immediately at post diagnosis.
Theme 2: Gaining education and knowledge supports the self-management of type two
diabetes
Tan et al., (2018), adopted descriptive qualitative design in their study using focus
group discussions in order to collect data. This methodology was chosen in the study as it
suited the purpose of study as the patients of diabetes experience it as daily phenomena.
Focus group discussions in the study are performed in less threatening environment that
encourage participants communicate and discuss opinions, thoughts, perceptions and ideas
regarding their experiences associated with diabetes. Semi structured interview was
performed which enables more systematic and comprehensive process of collecting data
which render most control for interviewer with structured format of question, enabling a
conversational tone in order to encourage participants to answer the questions in their own
way. The results from this study shows that the participants sampled in focus group
discussions from 3 ethnic groups share similar perceptions in context of their expectations,
needs and barriers in self-care activities of diabetes. The study found that the main factors
influencing the diabetic self-care management of elderly Singaporeans were perceived health
beliefs of individuals that affected their motivation and attitudes to maximize self-care
activities; work commitments which affected their regular patterns of physical exercise;
perceived difficulties in self-care activities like adopting healthy food choices that were seen
as not culturally congruent and unappetizing; forgetfulness that disrupt their regime for
medication; and high perceived requirement for information from nurses in doctors. The
findings of this study have significant implications in Singapore and in other Asian nations
where the populations are ageing as well as the prevalence of diabetes is increasing. The
findings from this study administers new culturally emphasized insights for clinical patient
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education within South East Asian context in order to enhance the self-care management of
diabetes of older adults. For instance, the study administers psychosocially based educational
interventions as well as addresses the cultural and generational misconceptions that diabetes
mellitus is not a serious issue, which presently detracts from the effectiveness of self-care
behaviour promotion efforts of diabetes.
Jarab et al., (2018), performed the study to explore the perspectives and experiences
of patients type 2 diabetes and its management. Apart from this, the study also explores views
regarding barriers to adherence to self-care activities and medications. Focus group
discussions was employed in the study which is a qualitative research approach and it was
guided through principal investigator (Aj) with assistance of (TM) who have experience in
caring for patients with diabetes. In the study, the audio tapes from focus groups were
transcribed verbatim as well as transcripts were checked in order to ensure accuracy against
original audio tapes. It has been found from the study that participants have less knowledge
about type 2 diabetes and they expressed variety of information needs associated with
medication regimens including potential side effects, type, therapeutic effect and dosing of
prescribed medications. Apart from this, it has been found from the study that additional to
poor knowledge regarding medications, therapeutic regimen characteristics is found to be a
main barrier to adherence of medication for study participants. Some patients in the study
exhibited high self-efficacy through emphasizing in the significance of individual
responsibility to follow recommendation for treatment as well as to accomplish the desired
clinical outcomes. The results from the study demonstrates that knowledge deficit along with
therapeutic regimen complexity, make it difficult for patients to adhere prescribed therapy.
The study findings useful to determine the components of future effective as well as specific
pharmaceutical care programs which are developed to enhance blood glucose control along
with other humanistic and clinical outcomes in patients with type 2 diabetes.
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The study performed by Tweahido, T and Berhene Y. (2017) makes use of qualitative
method This study employed semi structured interview guide for collecting data. Thematic
analysis approach was utilised to categorise the codes by several iterations. In total, 13 in-
depth interviews were performed with the patients with type 2 diabetes. It has been found
from the study that the comprehensive self-care practice of diabetes was uncommon among
patients. Most of the respondents in study entirely rely on medications for managing their
illness as well as tend to undermine the significance of other components of self-care because
of lack of resources, lack of support or negligence and lack of awareness. The outcomes of
the study show that irregularity of monitoring of blood sugar was the key shortcoming of
blood sugar level control which is precursor to development of long term complication of
diabetes. According to the study, personal food preferences and food habits in family were
the serious challenges that made dietary adjustment difficult individuals with diabetes. in
order to effectively control the blood sugar level, physical exercise is critical. The study
demonstrates that individuals with diabetes mellitus experience disproportionately high rates
of emotional and social difficulties in comparison to general population. Negative emotions
like feeling of helplessness and frustration contribute to poor self-practices involving poor
monitoring of blood sugar. The main strengths associated with the study includes its
minimum recall bias because of chronic nature of disease and it took a fresh approach for
self-care practices to selecting qualitative methods from perspective of patients, thereby
address previously unseen sides. However, some limitations of study also there including
absence of multiple method of Data collection, which is limited to interviews to the
individuals enrolled from public hospitals only. Apart from this, social desirability bias might
be introduced in the study despite the cautions taken at the time of interviews.
Herre et al., (2016) performed a study which aims to gain knowledge regarding how
individuals experience engaging in diabetes self-management courses with other individuals
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suffering from type 2 diabetes and the way they perceive this influences their health as well
as ability to self-manage the disease. Focus groups are selected for collecting the data in
study and Kondel's method was used to systematically coded and analysed the data. The
study underscored that participants in the study learnt through concrete experience as well as
by trying out practical task or activities through becoming part of diabetes community. By
experiencing different circumstances in real life scenarios, they felt safer about their own
treatment.
R. Abolghasemi, M. Sedaghat, performs a study that explores dimensions of attitudes
in diabetes mellitus patients regarding their disease. This study employed open semi
structured face to face interviews with 27 individuals. 18 themes were identified in the study
in four aspects of attitude including ethical approval, validity, reliability and analysing.
Implementation of findings
According to the study, personal food preferences and food habits in family were the
serious challenges that made dietary adjustment difficult individuals with diabetes. in order to
effectively control the blood sugar level, physical exercise is critical. The study demonstrates
that individuals with diabetes mellitus experience disproportionately high rates of emotional
and social difficulties in comparison to general population. The results from the study
demonstrates that knowledge deficit along with therapeutic regimen complexity, make it
difficult for patients to adhere prescribed therapy. The study findings useful to determine the
components of future effective as well as specific pharmaceutical care programs which are
developed to enhance blood glucose control along with other humanistic and clinical
outcomes in patients with type 2 diabetes. It has been found from this study that most of the
participants are aware of significance of self-management behaviours in order to control and
prevents the complications associated with diabetes. However, the key limitation of the study
15

involving that the sample was taken only from one diabetes centre in Baghdad. Thus, in order
to confirm the results of study, large study sample from district diabetes centres at district
Iraqi governorates is required.
It is very significant for the healthcare professionals as well as family members to
determine the significance of emotional burden which diabetes imposes as well as the
quantity and type of information people with diabetes prefer. apart from this it is also
important to consider health literacy levels in the community while developing the
information or programs associated with diabetes.
Conclusions
As per the above mentioned report, it has been concluded that diabetes is a serious
chronic disease which highly impacts on other organs of the body. Most of the participants
after studies have little knowledge and awareness about self-management of diabetes.
Healthy lifestyle, healthy eating, regular exercise etc. are the ways that help in preventing the
diabetes. Apart from this, it is very necessary that patient have proper understanding
regarding the disease as well as its proper management. The patients with diabetes mellitus
experience high rates of emotional and social difficulties as compared to general population.
This the most its deficit of knowledge regarding the disease. Proper treatment and
management of diseases very much required in order to stay healthy. The Community and
district nurses needs to provide continuous support to the patient as diabetes mellitus is a
complex issue and the individuals living with this chronic disease requires to take
responsibility of self-management of disease. It enables them to prevent future health
complications associated with the disease and contribute to improving the health and
wellbeing of people.
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mental health professionals. Elsevier Health Sciences.
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23

APPENDIX
Author, Year
and Title
Study Aims Study Design
Method
Data Collection
method
Methodological design strengths and
weaknesses (CASP analysis)
Main
Results arising from
study
Theme as
devised in
theming
table
Study 1:
Mikhael et al.,
(2019) Self-
management
knowledge and
practice of type
2 diabetes
mellitus
patients in
Baghdad, Iraq:
a qualitative
study.
Aims to
understand the
knowledge,
behaviours and
barriers of
diabetes self-
management
among Iraqi
type 2 diabetes
patients.
Primary
research:
Qualitative
Study.
Sampling
method:
Purposive and
Convenience
Sample size:
25 patients.
Sample
demographic:
12 males, 13
females. Age
ranged from 38-
73 years. 9
patients were
using insulin
alone, 9 were
using oral anti
diabetics and 7
were using
insulin and
metformin.
Data collection
method:
Strengths:
 Clear statement of the aims in
relation to the goals, the importance
of these and their relevance to the
study.
 Researcher used a qualitative
approach, which was appropriate in
gaining patients opinions and views
towards the study.
 The researcher clearly stated the
inclusion and exclusion criteria.
 Participants were recruited through
the National Diabetes Centre in
Baghdad, Iraq.
 Researchers did not work at the
clinic where the study was taking
place.
 Face to face semi-structured In-
depth interviews took place to
explore patients’ knowledge of type
2 diabetes, self-management
behaviours and their views and
opinions towards DSME
programmes.
 Transcripts were translated from
Out of the 15 major
categories 4 main
themes emerged in this
study: 1) General
knowledge about
diabetes and its
complications. 2)
diabetes self-
management. 3) Barriers
for Diabetes self-
management practices
(DSMP). 4) Diabetes
self-management
education (DSME).
Most participants agreed
to the importance of self-
management I.e. healthy
eating, exercise and
taking medications.
However, the patients
demonstrate a lack of
appropriate awareness of
the disease and how to
practice it effectively
1&2
24
Appendix

In-depth semi
structured
interviews were
conducted
lasting 35-70
minutes.
Arabic to English verbatim and
thematically analysed.
 The research was ethically approved
by national diabetes centre in
Baghdad, Iraq.
 Finding are discussed in relation to
the original research question.
 Results are compared with other
studies, with similar themes despite
cultural and other differences.
Weaknesses:
 Transcripts were not translated
independently and were transcribed
and coded by the first author which
could cause bias.
 Transcripts were not returned to the
participants to check and validate
the contents for accuracy.
 Recruitment took place from the
only diabetic centre in Baghdad,
Iraq.
 The study did not state why two
participants denied taking part in the
study, although they gave consent
prior to commencement.
and safely more so
during sick days. The
study also found,
patients were not
educated on the
importance of foot care
or what to do if a
hyperglycaemic event
took place.
Iraqi diabetic patients
lack adequate knowledge
regarding self-
management behaviours.
This was due to the lack
of self-management
educational programmes
in Iraq.
25

Author, Year
and Title
Study Aims Study Design
Method
Data
Collection
method
Methodological design strengths and
weaknesses (CASP analysis)
Main
Results arising from
study
Theme as
devised in
theming
table
Study 2:
Tan et al.,
(2018)
Perceptions of
diabetes self-
care
management
among older
Singaporeans
with type 2
diabetes: A
Qualitative
Study.
To explore the
experiences of
older
Singaporeans
with type 2
diabetes in
diabetes self-
care
management
to understand
their perceived
needs,
expectations,
and barriers
associated
with their
diabetes self-
care
management.
Primary
research:
Qualitative
Study.
Sampling
Method:
Purposive
Sample Size:
14 Patients
Sample
demographic:
9 males and 5
females aged
between 50-
71. 7 are of a
Chinese
descent, 4
Indian and 3
Malaysian.
Data
collection
method:
Open ended
semi-
structured
interviews in a
focus group.
Strengths:
 There was a clear statement of the
aims.
 The study was conducted in focus
groups which were divided into
ethnicity to avoid language bias.
 The author stated the inclusion and
exclusion criteria.
 Sampling was discontinued once
data saturation was reached and no
new insights or themes were found.
 Interviews were conducted using
semi-structured open-ended
questions based on self-management
framework.
 Discussion was audio taped and
transcribed verbatim. Data analysis
was carried out using the six-step
thematic analysis (Braun and Clarke,
2006).
 Ethical approval was granted from
the ethics committee and written
consent was gained from all the
participants.
 Author gave an explanation as to
why some participants dropped out.
 Rigor was ensured as data was
transcribed by the first author. It was
Although there were both
convergence and a
divergence of
perceptions in regard to
diabetes as a disease, the
patients shared similar
perceptions regarding
their needs, expectations
and barrier in diabetes
self-care. The key
psychosocial factors
influencing these patients
were:
1) Diabetes self-care
is difficult,
2) I don’t know
diabetes.
3) Doctors and
Nurses are
important
facilitators of
self-care
management
4) Diabetes is
genetic, destined,
and not serious,
complication, let
1
26

then counter checked by two
different authors to ensure the
authenticity and quality, thereafter
all the researchers validated and
agreed with all the emerging themes.
Weaknesses:
 Patients confidentiality was not
mentioned.
 Only three ethnic groups participated
in the study (Chinese, Malay and
Indian).
 Group sizes were small and uneven
i.e. 7 Chinese, four Indian and three
Malay.
it come.
The key psychophysical
factors influencing these
themes were; perceived
individual’s health
beliefs, which affected
their attitudes and
motivation to increase
self-care activities;
perceived difficulties in
adopting healthier foods;
work commitments that
affected their physical
exercise patterns;
forgetfulness affecting
their medication regime
and a high need to
information from Drs
and Nurses.
27

Author, Year
and Title
Study Aims Study Design
Method
Data
Collection
method
Methodological design strengths and
weaknesses (CASP analysis)
Main
Results arising from
study
Theme as
devised in
theming
table
Study 3:
Jarab et al.,
(2018)
A focus group
study of
patient’s
perspective and
experiences of
type 2 diabetes
and its
management in
Jordan.
To explore
the patients’
perspectives
and
experiences
of type 2
diabetes and
its
management.
Primary
Research:
Qualitative
Study.
Sampling
Method:
Purposive
Sample Size:
36 participants
Sample
demographic:
6 focus groups
containing 6
participants
each.
Data
collection
method:
Focus group
discussion.
Audio tapes
Strengths:
 Clear statement of the aims in relation
to the goals, the importance of these
and their relevance to the study.
 Researcher used a qualitative
approach, which was appropriate to
address the research goals by
illuminating participants experiences
and justified by the researchers.
 The researcher clearly stated the
inclusion and exclusion criteria.
 Researchers did not have any
previous relation or history with any
of the participants and did not work at
the clinic where the study was taking
place.
 Focus groups were small and open-
ended questions were used to explore
patients’ perspectives and
experiences.
 Transcripts were translated by two
independent translators. Responses
were given in Arabic and then
translated into English then back into
Arabic to ensure accuracy.
 Transcripts were coded
independently, and data was analysed
using the thematic analysis approach
Four major themes were
highlighted from this
focus group study: 1)
knowledge and
information needs
regarding diabetes and
self-management, 2)
barriers to adherence to
medications 3) self-
efficacy and 4) Health
beliefs and beliefs about
illness.
The patients generally
demonstrated poor
knowledge about type 2
diabetes and stated that
clear information needed
to be given relating to
dose, effects, potential
side effects and the length
of time required to
achieve desired blood
glucose levels. The
participants also showed
a lack of interest in self
efficacy and had negative
attitude and beliefs about
1
28

which was used to record the
emerging themes.
 The research was ethically approved.
 Finding are discussed in relation to
the original research question.
 Results are compared with other
studies, supporting findings so that
results can be applied locally, despite
cultural and other differences. Similar
programmes could be introduced to
treat the consistent symptoms of
diabetes.
Weaknesses:
 Final themes were not validated by
the participants.
 Transcripts could be influenced by the
prior perceptions of the researchers.
 Participants may have adjusted their
own responses to those in the focus
group.
the illness.
The study revealed future
individualized self-
management educational
programmes should be
considered for patients to
manage type 2 diabetes
more efficiently and
effectively. Thus,
increasing awareness and
the importance in
managing type 2 diabetes.
Author, Year
and Title
Study Aims Study Design
Method
Data Collection
method
Methodological design strengths and
weaknesses (CASP analysis)
Main
Results arising from
study
Theme as
devised in
theming
table
Study 4:
Tweahido, T
and Berhene
Y. (2017)
To describe
self-care
practices
among
Primary
research:
Qualitative
Sampling Method:
Purposive
Sample Size:
Strengths:
 Clear statement of aims in
relation to describing self-care
practices amongst patients with
Three different groups
were categorised under
diabetes self-care
experiences:
1&2
29

Self-Care
practices
among
diabetes
patients in
Addis Ababa:
A qualitative
study.
individuals
with type 2
diabetes.
Study. 13 participants
Sample demographic:
All patients had
diabetes for at least 5
years. 7 females and 6
males. Aged between
35-65.
Data collection
method:
In-depth interviews.
type diabetes.
 Participants were recruited
attending a follow up
appointment at the local diabetic
clinic.
 Inclusion and exclusion criteria
was provided. All participants
gave verbal consent prior to
interviews.
 Researcher used a qualitative
approach as this was best in
answering participants lived
experiences.
 The researcher used a semi-
structured interview guide by
reviewing previous literature and
participants were encouraged to
speak their minds.
 The researchers piloted the
questions in another hospital to
assess the ease and understanding
of the interview questions and
changes where therefore made
before going forward with the
actual interviews.
 All the interviews were recorded
and transcribed verbatim
Weaknesses:
 Participants were aged between 35-
65 years old.
1) Negligent
2) Confused
3) Endeavour to
be compliant
Self-care practices
overall were
inadequate. Dietary
and physical exercise
were also poorly
managed by the
participants. Most
patients adhered to
medication
prescriptions. Diabetes
self-care is generally
poor due to insufficient
guidance and support
available to patients
with diabetes as
patients mainly lacked
proper
information/knowledge
regarding the
importance of self-
care.
30

 Only chose participants from 2 out of
the 5 hospitals available.
 Lacked external validity.
Author, Year
and Title
Study Aims Study Design
Method
Data Collection
method
Methodological design strengths and
weaknesses (CASP analysis)
Main
Results arising from
study
Theme as
devised in
theming
table
Study 5:
Herre et al.,
(2016)
Experience of
knowledge
and skills that
are essential
in
self-
managing a
chronic
condition – a
focus group
study
among people
with type 2
diabetes.
To gain new
knowledge
about how
people
experience
participating in
diabetes
self-
management
courses with
other people
with type
2 diabetes and
how they
perceive this
influences there
health and
ability to self-
manage the
disease.
Primary
research:
Qualitative
Methodology.
Sampling
Method:
Purposive
Sample Size:
22 Participants
Sample
demographic:
11 Women
11 Men
Aged between
30-75
Data collection
method:
Five focus
groups
participated in a
group-based
diabetes self-
management
Strengths:
 Clear statement of the aims of the
research in relation to the goals, the
importance of these and their
relevance.
 A qualitative approach was appropriate
to address the research goals by
illuminating participants’ experiences.
 The research design was appropriate to
address the aims of the research, the
design fully justified by the
researchers.
 The research strategy was appropriate
to the aims of the research.
Researchers’ explained how
participants were selected and why
they were most appropriate to gain
specific knowledge.
 Data was collected in a way that
addressed the research issue. The
setting, the data collection method and
how data was collected were justified.
 Participants gained
more specific
knowledge by
participating in a
group setting.
 They increased
theoretical and
practical
understanding of
how to handle
diabetes in everyday
life.
 The diabetes self-
management course
made the
participants more
aware of taking the
disease more
seriously.
 Learning by being
in the situation
while guided by
1&2
31

course. Explicit method, using interview guide
and the form of data is clear.
 Ethical issues have been taken into
consideration with voluntary
participation, anonymity maintained,
and written consent gained. Research
conducted in accordance with the
Helsinki Declaration and the
Norwegian Social Science Data
Services.
 Data analysis was sufficiently rigorous
with an in-depth description of the
analysis process, thematic analysis
supported by data coded to aid
interpretation. Sufficient data are
presented to support the findings.
 Findings are discussed in relation to the
original research question.
 The research is valuable as it supports
the need to educate diabetics in the
complications related to the disease and
how increased knowledge shared
supports self-management.
Weaknesses:
 No discussions around recruitment and
why some people chose not to take
part.
 Participants were not provided with the
same length of course (2 or 3 days).
 Saturation of data is not discussed.
 It is unclear if the relationship between
researcher and participants has been
professionals was
useful and learning
from each other by
carrying out real
tasks in a context
with others
struggling with
similar treatment
demands.
 Web-based
solutions cannot
replace the practical
parts or the dialogue
between the
participants.
 They expressed
both a need and a
wish for a refresher
course.
32

adequately considered, as there are no
details regarding whether they
critically examined their own role,
potential bias and influence during
analysis and selection of data.
 Contradictory data is not considered.
 Although findings are clearly stated
they do not consider evidence against
the researchers’ arguments and
credibility of findings are not
discussed.
 Researchers do not discuss whether
findings can be transferred to other
populations or considered other ways
the research may be used.
Author, Year
and Title
Study Aims Study Design
Method
Data Collection
method
Methodological design strengths and
weaknesses (CASP analysis)
Main
Results arising from study
Theme
as
devised
in
theming
table
Study 6:
O’Brien et
al., (2015)
Self-
Management
experiences
of persons
living with
diabetes
mellitus type
The aim of the
study was to
explore and
describe the
experiences of
persons living
with type 2
diabetes related
to self-
management.
Qualitative
Study.
Sampling
Method:
Purposive
Sample Size:
19 Participants
Sample
demographic:
13 Female
Strengths:
 There is a clear statement of the aims.
 A qualitative framework was used for
this study to explore participant’s
thoughts, opinions and feelings.
 The researcher explained the
recruitment strategy and how the
participants were selected.
 An inclusion and exclusion criteria was
included.
5 main themes emerged
from the study.
 The participants
experienced a wide
range of emotions on
initial diagnosis.
 The participants
gradually experience
an acceptance and
acknowledgment of
2
33

2. 6 Male
Ages ranged
from 44 to 74
years.
Data collection
method:
Semi structured
individual
interviews.
 An informed and verbal consent was
gained prior to the interviews taking
place and recorded.
 Semi-structured individual interviews
were developed for data collection in
the privacy of the patients’ home.
 Data collection was continued until data
saturation was achieved. The
participants were allowed to elaborate
further on their experiences of living
with type 2 diabetes and field notes
were taken by the interviewer.
 The data was coded to ensure privacy
and confidentiality was maintained.
 Tesch’s (2013) method of thematic
analysis was used to allow for rigor in
identifying topics and themes. An
independent coder assisted with
identifying the themes separate to the
researcher.
 The researcher has explained the
trustworthiness of the study by
addressing the credibility,
transferability, dependability and
confirmability.
 Ethical approval was given by the ethics
committee of a local university.
 Findings are discussed in relation to the
original question.
 This research is valuable as
Weaknesses:
their condition.
 The participants have
definite opinions and
concept of self-
management.
 Participants
acknowledge both
positive and negative
factors which
influence self-
management.
 Participants expressed
views on how
professional nurses
can assist them in
achieving self-
management.
34

 Participants were recruited from one
area. Which would limit the results.
 Participants were aged from 44-74
years old.
 14 participants used private health care
facilities, whilst 3 used public.
35

36
Author, Year
and Title
Study Aims Study Design
Method
Data Collection
method
Methodological design strengths and
weaknesses (CASP analysis)
Main
Results arising from
study
Theme as
devised in
theming
table
Study 7:
Carolan et al.,
(2014)
Experiences of
diabetes self-
management: a
focus group
study among
Australians
with type 2
diabetes.
To explore the
experiences
and concerns
of individuals
with type 2
diabetes
mellitus, in a
predominantly
low socio-
economic
setting.
Qualitative
design.
Sampling
Method:
Purposive
Sample Size:
22 Participants
Sample
demographic:
10 Male and 12
Female
3 aged 40-49
6 aged 50-59
8 aged 60-69
5 aged over 70
with type 2
diabetes mellitus,
who were
attending local
health services
for their diabetes
care.
Data collection
method:
Four focus
groups of four to
eight participants
were asked open
ended questions.
Strengths:
 There was a clear statement of the
aims of the research, its relevance,
importance and goal.
 A qualitative methodology is
appropriate as the research seeks to
identify subjective experiences of
participants and it addresses the
research goal.
 The recruitment strategy supported
the aims of the study, the researchers
explaining how participants were
selected with discussion surrounding
process.
 Data was collected in a way that
addressed the research issue, data
collected through focus groups.
 After all questions were answered and
invitations for further comments and
questions were exhausted, saturation
of data was achieved.
 Ethical issues were considered,
ethical approval granted prior to study
commencement and written consent
gained at focus groups. Pseudonyms
were used to maintain participant
confidentiality.
 Data analysis was sufficiently
rigorous, with an in-depth description
of the analysis process. Thematic
analysis was used with discussion
regarding how these were derived
from the data. Sufficient data are
presented to support the findings.
 There is a clear statement of findings,
credibility supported by three
researchers independently analysing
data and findings are discussed in
relation to the original research
Participants described
their experiences of
managing their diabetes
as emotionally,
physically and socially
challenging. Data
analysis revealed four
main themes including:
(1) diabetes the silent
disease; (2) a personal
journey (3) the work of
managing diabetes; and
(4) access to resources
and services.
Participants highlighted
the impact of diabetes
on the family, and the
importance of family
members in providing
support and
encouragement to assist
their self- management
efforts.
2

Author, Year
and Title
Study Aims Study Design
Method
Data Collection
method
Methodological design strengths and
weaknesses (CASP analysis)
Main
Results arising from
study
Theme as
devised in
theming
table
Study 8:
Abolghasemi R
and Sedaghat
M (2014)
The patients’
attitude towards
type 2 diabetes
mellitus: A
qualitative
study.
To explore
dimensions
and attitudes
in diabetic
patients
about their
disease.
Primary
research:
Qualitative
Study.
Sampling Method:
Purposeful
sampling
Sample Size:
27 Patients
Sample
demographic:
22 female and 5
male.
Age ranging 21-86
years.
23 patients were on
antidiabetic
medication and 4
on insulin.
Data collection
method:
Open semi-
structured face to
face interviews.
Strengths:
 There was a clear aim to
explore dimension of attitudes
in diabetic patients about type 2
diabetes.
 A qualitative approach was
chosen for this study as the
researchers wanted to carry out
a phenomenon study based on
patients’ experiences.
 Participants
 Semi-structured open-ended
questions to cover four domains
of WHO definition of diabetes
were used to explore patients’
experiences.
 Interviews were audio taped
and handwritten notes were
made in relation to non-verbal
communication i.e. observation
of feelings and reflection.
 Researchers allowed the
patients to tell their story in
their own words enhancing the
credibility of the study.
 Researchers had no previous
Eighteen themes were
identified in four aspects
of attitude: physical,
mental, social and
spiritual. They were then
divided into two broad
theme categories;
1) Progress attitude
towards the highest
degree
2) Inhibited attitude to
be progressed.
Furthermore, participants
did not have enough
knowledge about causes
of diabetes, the
difference between type1
and type 2, the correct
nutrition and activity and
exercise.
The results need
consideration in
designing and creating
educational initiatives
aimed for promoting
1
37

interactions with the patients or
the diabetic centre prior to this
study.
Weaknesses:
 Did not give reason as to why 3
participants dropped out.
 Researcher does not state
inclusion and exclusion criteria.
 Research stated they use two
new style of qualitative studies
but didn’t provide any detail as
to what the studies where.
patient management.
Author, Year
and Title
Study Aims Study Design
Method
Data
Collection
method
Methodological design strengths and
weaknesses (CASP analysis)
Main
Results arising from
study
Theme as
devised in
theming
table
Study 9:
Matthew et
al., (2012)
Self-
management
experiences
among men
and women
with type 2
diabetes
To understand
the differences
in diabetes
self-
management,
specifically
needs, barriers
and challenges
among men
and women
Qualitative
Study.
Sampling
Method:
Purposeful
Sample Size:
35 participants
Sample
demographic:
17 Men
Strengths:
 The researcher seeks to find out the
phenomenon of self-managing type 2
diabetes.
 The author used Brewer-Lowry et al
(2010) self-management framework
to direct interviews as it describes
diabetes self-management in
intersections i.e. diet, physical, foot
care and glucose monitoring.
The focus of this study
was to explore diabetes
self-management
experiences, specifically
needs, challenges and
barriers between men
and women with type 2
diabetes.
The study highlighted 5
2
38

mellitus: a
qualitative
analysis
living with
type 2
diabetes.
average of 55
years of age
18 Women
average age of
64.
Data
collection
method:
Open ended
semi
structured
interview
questions.
26 participants
took part in
focus groups.
9 telephone
interviews
were
conducted.
 The author contacted the eligible
participants according to their
exclusion and inclusion list.
 26 participants took part in focus
groups: one group had a mixed sex
group and two groups had men only
and two groups with women to allow
for sex specific discussion.
 The 9 participants who could not
attend the focus groups engaged in
telephone interviews.
 Data analysis was sufficiently
rigorous, with an in-depth
description of the analysis process.
Thematic analysis was used with
discussion regarding how these were
derived from the data. Sufficient data
are presented to support the findings.
 There is a clear statement of
findings, credibility supported by
four researchers independently
analysing the data and findings are
discussed in relation to the original
research question.
 The research is valuable as it
identifies unmet needs and worries
of diabetics specifically in men and
the need to address knowledge,
dietary support of diabetics to
support self-management.
Weaknesses:
over-arching themes:
1. Identity and
disclosure as person
living with diabetes
2. Self-monitoring of
blood glucose
3. Diet struggles
4. Utilization of
diabetes resources
5. Social support
The findings allowed the
researchers to develop a
more comprehensive
understanding of the self-
management experiences
amongst men and
women. This study will
inform healthcare
practice and counselling
by illuminating the
complex factors of
gender differences.
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 Group sizes were not well balanced:
three to eight participants per focus
group based on availability.
 Over half of the participants were
recruited based on attending the
education programme available at
the diabetic education centre as the
other half of the participants did not
return after their initial visit.
Author, Year
and Title
Study Aims Study Design
Method
Data
Collection
method
Methodological design strengths and
weaknesses (CASP analysis)
Main
Results arising from
study
Theme as
devised in
theming
table
Study 10:
Lundberg PC
and Thrakul
S. (2011)
Diabetes type 2
self-
management
among Thai
Muslim
women.
To explore and
describe Thai
Muslim
women’s self-
management
of type 2
diabetes.
Primary
research:
Qualitative
Study.
Sampling
method:
Purposive
convenience.
Sample size:
29 women
aged between
40-80 years.
Suffered with
diabetes
between 3-31
years. 20
participants
used anti-
Strengths:
 The aims in this study were clear
 An explorative qualitative study using
ethnography was conducted.
 The researcher stated the inclusion and
exclusion criteria.
 The study was approved by the ethical
committee of the faculty of medicine of
university of Bangkok.
 All participants had been fully informed
and consented and assured anonymity
and confidentiality would be maintained.
 Semi-structured interviews were
conducted, and 4 open ended questions
The study found Thai
women suffered from a
partial self-care deficit:
The study highlighted
four themes:
1. Daily life practice
2. Impact of illness
3. Everyday life as
before
4. Family support
Th study also illuminated
recommendations for
change to occur in
2
40

diabetes
drugs, 6 used
insulin and 3
used diet
control only.
Data
collection
methods:
participated in
one to one
interviews in
the
individuals
home.
were asked followed by the participants
were allowed to express themselves in
relation to how they manage diabetes.
 The interviews were recorded and
conducted in the comfort of the
participants homes.
 The interviews were translated verbatim
from Thai to English and checked by a
language expert. The interviews were
also peer checked by two experts with
experience of the research method and
the subject.
Weaknesses:
 The study was small and exploratory
and may not be used to generalise
the result for the population of
Thailand itself.
 Participants were recruited living in
the catchment area of a university
hospital.
 participants names were not kept
anonymous and confidential.
clinical practice; for
professionals to stimulate
their patients to adjust
their daily behaviour
whilst understanding the
roles of cultural
background, religious
traditions and family on
the basis of educating
and helping patients to
integrate self-
management into their
daily lives.
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42
Published Results Grouped Results Themes
1. Mikhael et al., (2019)
1) General knowledge about diabetes and its
complications.
2) Diabetes self-management.
3) Barriers for Diabetes self-management practices
(DSMP).
4) Diabetes self-management education (DSME).
2. Tan et al., (2018)
1) Diabetes self-care is difficult; resistance to lifestyle
modifications to increase diabetes self-care activities.
2) Inadequate health information and lack of
understanding about the disease.
3) Doctors and Nurses are important facilitators of self-
care management
4) Poor knowledge and perceptions of diabetes as patients
refer to diabetes being a hereditary disease.
3. Jarab et al., (2018)
1) Knowledge and information need regarding diabetes
and self-management
2) Barriers to adherence to medications
3) Self-efficacy
4) Health beliefs and beliefs about illness.
4. Tweahido, T and Berhene Y. (2017)
Three different groups were categorised under diabetes self-
care experiences:
1) Negligent – resist self-care recommendations;
consequently, patients self-care practice is very limited
and uncommitted.
2) Confused – patients are lacking information and
education on self-care practices.
3) Endeavour to be compliant – reaching out to peers,
doctors and nurses can increase awareness of
Group 1:
Mikhael et al., (2019)
Tan et al., (2018)
Jarab et al., (2018)
Tweahido, T and Berhene Y. (2017)
Herre et al., (2016)
Abolghasemi R and Sedaghat M (2014)
Group 2:
O’Brien et al., (2015)
Carolan et al., (2014)
Matthew et al., (2012)
Lundberg et al., (2011)
Theme 1:
Gaining education and knowledge supports the
self-management of type two diabetes.
Theme 2:
Experiences of self-management of type two
diabetes.

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