Challenges Faced by People with Diabetes in Accessing Information and Medical Care

This dissertation explores the challenges faced by individuals with diabetes in accessing information and medical care. It identifies barriers such as lack of knowledge, lack of support, psychosocial issues, and socioeconomic factors. The dissertation emphasizes the importance of awareness and support in improving the health and wellbeing of diabetes patients.

Running head: DISSERTATION
What are the main challenges do people with diabetes face when accessing information and
medical care?
Name of the Student
Name of the University
Author Note

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Abstract
This dissertation aimed to explore what are the barriers that are faced by individuals with
diabetes, in relation to accessing information and clinical care services. Three electronic
databases MEDLINE, CINAHL, and EMBASE were sued to select 11 primary research
articles, from which four promising themes were identified: (i) lack of knowledge and
awareness among patients, (ii) lack of motivation and support from peers and family, (iii)
psychosocial issues related to diabetes self-management, and (iv) low educational attainment
and poor socioeconomic status of patients. On top of this, the dissertation indicated that there
are several misconceptions and stigma about diabetes in different cultures that hinder the care
seeking process. Thus, the provision of care giving must take into consideration the presence
of adequate awareness on the disease, in addition to the presence of necessary social and
financial support. Finally, the dissertation called for future formulation of education
campaigns and policies that would address the identified barriers and improve health and
wellbeing of diabetes patients.
Keywords: diabetes, barriers, management, access, care

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Table of Contents
Introduction................................................................................................................................3
Background............................................................................................................................3
Research question.......................................................................................................................5
Research aim..............................................................................................................................5
Research objectives....................................................................................................................5
Literature review methodology..................................................................................................6
Purpose statement...................................................................................................................6
Selection criteria.....................................................................................................................7
Search terms...........................................................................................................................7
Relevance assessment............................................................................................................8
Quality appraisal....................................................................................................................9
Results......................................................................................................................................10
Lack of knowledge and awareness among patients.............................................................10
Lack of support and motivation from family and peers.......................................................11
Educational attainment and socioeconomic condition of the patients.................................12
Psychosocial issues related to self-management of diabetes...............................................13
Discussion................................................................................................................................16
Conclusion................................................................................................................................20
Implications..........................................................................................................................21
References................................................................................................................................22
Appendices...............................................................................................................................27

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Introduction
Background
Commonly referred to as diabetes, diabetes mellitus is a metabolic disorder that is
characterized by increased blood sugar levels. Some of the common symptoms of diabetes
mellitus include increased thirst, frequent urination, and increase hunger. If not treated
properly, the condition can result in several health complications such as, hyperglycaemic
state, diabetic ketoacidosis, or even death (American Diabetes Association 2014). Other
serious complications comprise of stroke, cardiovascular disease, foot ulcer, chronic kidney
disease, and eye damage. The condition typically arises due to failure of the pancreas in
producing adequate insulin. It also occurs when the cells present in the body are not able to
respond appropriately to the amount of insulin that has been produced from the pancreas.
Three major types of diabetes mellitus are namely, (i) type 1, (ii) type 2, and (iii) gestational
diabetes (Macedo et al., 2014). The principal goal of diabetes management focuses on
restoring carbohydrate metabolism to normal levels. With the aim of accomplishing this goal,
people who suffer from an absolute deficiency of the hormone insulin, require external
insulin replacement therapy that is typically administered through insulin pump or injection.
Exercise and dietary modifications are other management strategies that help in combating
insulin resistance (Holt and Kumar 2015). Secondary goals of diabetes management focus on
preventing or delaying the onset of other co-morbid conditions.
The number of individuals who have been diagnosed with diabetes in the United
Kingdom has increased to 3.5 million in recent years from 1.4 million, as per records of 1996.
Taking into consideration the proportion of people who are likely to be residing with
undiagnosed diabetes in the UK, the number is expected to be as much as 4 million

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(Diabetes.co.uk 2018). The prevalence of diabetes in the UK is estimated to increase to
roughly 5 million by the year 2025, with prevalence and incidence of type 2 diabetes
increasing at a rapid rate. Hence, recent records suggest that roughly 6% of the entire UK
population, which accounts for one in 16 people, have diabetes which is either diagnosed or
undiagnosed. Higher prevalence of this metabolic syndrome is found in England, followed by
Scotland, Wales, and Northern Ireland. According to reports from the International Diabetes
Federation, the top five nations that have greatest proportion of individuals with diabetes are
namely, China, India, the USA, Brazil, and the Russian Federation, with 109, 69, 29, 14, and
12 million people, respectively (Atlas 2015).
Patient access to appropriate healthcare amenities set the foundation for all client
interactions with the healthcare industry, as defined by Penchansky and Thomas's Theory of
Access (Usher 2015). According to Menke et al. (2015) under circumstances when patients
are not able to access appropriate healthcare services, it becomes impossible to receive
appropriate facilities, build therapeutic relationship with the providers, and accomplish
overall wellness and health. Despite the growing importance of access to healthcare, it has
not yet become a reality for several people residing across the nation. Apart from troubles in
reaching the clinician centres, and appointment availability issues, several challenges are
associated with patient care access, which hinder the process of self-health management.
There is mounting evidence for the fact that problems with the existing medical infrastructure
and socioeconomic status play an important role in preventing hassle free delivery of diabetes
care services (Kivimäki et al. 2015). Failure of the healthcare providers in accurately
monitoring the diabetic patients, and considering them for follow-up also makes the patient
encounter several challenges. Unhealthy food habits, lack of physical exercise, obesity,
urbanisation and population growth are the primary reasons for the ever-increasing
pervasiveness of diabetes. Lack of knowledge among patients about diabetes mellitus also

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hinders their capability to effectively manage the illness (Deepa et al. 2014). Awareness
levels typically increase with education, and patients having greater educational attainment
have better knowledge that the metabolic syndrome is preventable. According to Mumu et al.
(2014) major challenge is also associated with the fact that patients do not have adequate
information about the risk factors that can aggravate their health condition, and result in the
onset of several co-morbidities. One major aspect of diabetes management and care is
satisfactory treatment and timely diagnosis, in the absence of which several co-morbidity and
complications can arise drastically. Access and availability to diabetes drug is another
feature. Not all people who have been affected with this condition are able to access anti-
diabetic pharmaceutical agents. Additional administration of insulin is also delayed in several
patients, until it becomes absolutely necessary to externally administer the hormone, for
keeping a check on the deteriorating HbA1C levels. This calls for the need of conducting a
research in determining the challenges faced.
Research question
What main challenges do people with diabetes face when accessing information and
medical care?
Research aim
To determine the challenges that people suffering from diabetes encounter, while
accessing medical care and health information.
Research objectives
 To determine the barriers faced by patients
 To explore the awareness of diabetes management and care among patients

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Literature review methodology
Systematic reviews have the potential advantage of providing objective summaries of
information that has already been published in written, about several research topics. This is
particularly valuable in wide research domains, where there exist several publications, each
of which focus on a narrow facet of the phenomenon under investigation. While traditional
reviews encompass publications that discuss and describe the state of science, of a particular
theme on topic from a contextual and theoretical point of view, systematic reviews have the
primary objective of providing a comprehensive overview of research that has been
conducted in that specific domain, until the current date (Peters et al. 2015). Hence, a
systematic review was conducted with the use of rigorous methodological approaches, for
identifying scholarly articles that contain information on the challenges that people face, in
relation to diabetes care and management.
With the aim of conducting a literature review on the aforementioned topic, a three-
stage procedure was formulated that encompassed (i) planning, (ii) conducting, and (iii)
reporting. The planning phase comprised of forming a review panel that consisted of two
independent experts in the particular domain. The structured approach that was followed
while conducting the systematic review was based on the 12-step framework proposed by
Kable, Pich and Maslin-Prothero (2012). A comprehensive documentation of the search
strategy helped in providing a clear explanation for the focus and rationale of the review.
The Framework also provided guidance through the strategy development and helped in
ensuring that no essential aspects were left out.

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Purpose statement
The purpose was formulated under the guidance of the project supervisor. The
purpose was stipulated as exploring the challenges that People suffering from diabetes have
to encounter while accessing information and medical care.
Selection criteria
The inclusion and exclusion criteria developed for the literature review manifested the
main focus of the research and also highlighted the resource limits. Although it is typically
considered essential for including grey literature in systematic review, it was difficult to
locate abundant grey literature within the specified time range for conducting the review
(Stern, Jordan and McArthur 2014). The inclusion and exclusion criteria are given below:
Inclusion criteria Exclusion criteria
Articles published in English Articles published in foreign languages
Articles published on or after 2014 Articles published prior to 2014
Articles that focus on diabetes Articles that focus on other metabolic
syndrome
Articles that contain information on barriers
or hindrances to diabetes care and
management
Abstracts
Primary research articles Case series and clinical guidelines
Peer reviewed articles Secondary research articles
Accepted manuscripts
Table 1- Inclusion and exclusion criteria for the proposed literature review

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Search terms
The second stage of conducting the literature review comprised of formulation of
search terms, on the basis of discussions and scoping studies within the panel. While
developing suitable search terms that would help in extraction of literature that were pertinent
to the research question, the 2009 guideline by the Centre for Reviews and Dissemination’s
(CRD) was taken into consideration, which provided the suggestion for consulting the
principal research question (Zeng et al. 2015). As per the guideline, abbreviations, spelling
variance, and synonyms were considered. MEDLINE, CINAHL, and EMBASE electronic
databases were extensively searched for retrieving articles.
The reference lists of the articles were also manually searched, thus utilizing the
procedure of snowballing. Hand searching the bibliography of the articles and consulting the
citation analysis, helped in discovering studies that were relatable to the review. The search
terms used were “diabetes”, “care”, “management”, “barriers”, “challenges”, “hindrances”,
“people”, “access”, “information”, and “patients” that were combined with boolean operators
AND, NOT and OR (McGowan et al. 2016).
Relevance assessment
Followed by retrieval of several articles from the electronic databases, bibliography
search and citation analysis, the PRISMA (Preferred Reporting Items for Systematic Reviews
and Meta-Analyses) was used for determining relevance of the retrieved scholarly literature,
at the end of search process (Moher et al. 2015). The articles were evaluated in a three-stage
process by assessing them against the criteria. Initially all the titles of the obtained hits were
evaluated, which had the potential advantage of the fact that the literature, which did not meet
the rational of the intended research, could be eliminated within a comparatively short period
of time. Under circumstances when the article title had limited information for judging its
relevance, it was included within the list. All the steps were conducted separately by two

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individual researchers, following which disagreements were resolved by participating in
group discussions that resulted in refinement of the search criteria (Booth 2016). The initial
hits of 103 articles were decreased to 58.
The second screening step comprised of reading and assessing the abstract of all 58
articles against the formulated criteria and duplicate removal. Complete articles with less
informative abstracts were also added to the list. At the end of the second screening phase,
roughly 24 scholarly literatures remained. The third screening phase was conducted by
determining the full text eligibility of the articles. This resulted in exclusion of 13 articles
from the analysis in the final step, thereby leading to a final batch of 11 articles that were
included in this review. Resource and time limitation of the systematic review did not permit
for complete inclusion of other researches for assessing representativeness of the included
articles. This makes the systematic review slightly vulnerable of being subjectively biased,
thus not completely providing a representative overview of the contemporary status of
investigation. While a complete representative review is typically needed and aspired by
science, this paper will provide other researchers the foundation for imitating the research
procedure, and assessing its findings. My personal values initially influenced the decision of
formulating search terms since I wanted to focus on barriers that are generally faced by
people with diabetes in the UK. However, a discussion with my supervisor helped me
understand that restricting the review population to the UK would prevent generalizability of
our findings and would also decrease representativeness of the results we obtained. Appendix
A contains the PRISMA flowchart.
Quality appraisal
At the end of determining the relevance of the included article, all 11 literatures were
thoroughly analysed and appraised, for ensuring reliability of the information reported in

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them. Their internal and external validity, findings, and relevance to the current research were
also determined.

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Results
The 11 studies that were included in the qualitative data synthesis resulted in the
identification of four major themes. Of the 11 studies that were included, three were
quantitative and focused on questionnaires and surveys as the data collection tools, following
which the responses of the patients were statistically represented. The rest eight studies were
based on qualitative research design and included surveys, focus groups, semi-structured
interviews or a combination of both. The most frequently occurring and noticeable themes
comprised of (i) lack of knowledge and awareness of diabetes management and care services,
(ii) lack of support and motivation from family and peers, (iii) psychosocial issues associated
with self-management of diabetes, and (iv) poor socioeconomic status and educational
attainment of the patients.
Lack of knowledge and awareness among patients
Sufficient knowledge was also associated with accurate medication taking, exercise,
diet, foot care and blood glucose monitoring. Booth et al. (2013) and Hu et al. (2013) stressed
on the fact that low levels of understanding among diabetes patients and their family
members often resulted in their failure in realising the management steps that they should
adopt. Additionally, vast amount of information on diabetes care also confused the patients in
adequately seeking care services and maintaining blood glucose levels. This was in
accordance to the findings presented by Sina, Graffy and Simmons (2018) who suggested that
patients often have inadequate knowledge about diabetes management and its allied care
services. On conducting a statistical analysis they reported that 408 and 340 patients with no
reported diabetes complications cited lack of awareness on diabetes and diabetes service as
the major barrier to proper healthcare, respectively. In addition, 355 people who reported
diabetes complications also identified poor diabetes knowledge as a major barrier in self-care
and management.

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Findings reported by Tong, Vethakkan and Ng (2015) also elaborated on the fact that
diabetes patients were often participants were not aware of the extent to which they should
regulate blood sugar. Absence of adequate knowledge on management of diabetes was also
cited as a major barrier by Yasa et al. (2018) and Ong, Chua and Ng (2014) also supported
the aforementioned findings by illustrating that diabetes patients lacked adequate
understanding on the steps needed to care for themselves and frequently considered self-
management as unnecessary, which in turn resulted them to alter the manner in which they
kept a check on their blood glucose levels. Mogre et al. (2019) also affirmed the
aforediscussed facts and stated that healthcare professionals were often of the view that the
patients who are able to have enough money a glucometer found it problematic to either
operate it or had encounters while doing unit conversions since majority of the self-
management units have dissimilar calibrations. Hence, the findings from the articles
elaborated on the importance of proper diabetes education in improving the attitude and
knowledge of the patients towards diabetes access and management.
Lack of support and motivation from family and peers
Lack of social support was recognised as a major barrier by McBrien et al. (2017)
who cited that patients manifesting poor glycaemic control had an increased likelihood of
reported absence of confidence in strictly adhering to diabetes treatment plan, owing to their
reduced probability of obtaining support from others. In the study conducted by Sina, Graffy
and Simmons (2018) some of the most common psychosocial barriers that were identified by
the participants were namely, lack of support in the form of pressure from others of not
looking after them, absence of social closeness and support at work or in the community, and
prejudice or stigma that were held against them for suffering from the metabolic syndrome.
Family demand was also identified to hinder proper diabetes care behaviour. Inadequate
family support was also cited as an important barrier by Mogre et al. (2019) where the

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healthcare providers stated that support and assistance from the family was imperative in
successful self-management of the metabolic syndrome and was particularly necessary for
making the patients show adherence to prescribed medications and dietary recommendations.
Most diabetes patients experienced lack of support from the family, particularly in
terms of adhering to dietary modifications and medications (Hu et al. 2013). It was also
stated that inspiration for behaviours with outcomes not directly apparent, such as, healthy
food habits also played an important role in accessing diabetes care services. The patients
often found it difficult to show adherence to situations where they were under medications or
had to follow diet patterns that were different from the rest of their family members (Booth et
al. 2013). This was in accordance to the findings presented by Mayberry et al. (2018) who
stated that lack of emotional closeness with people who act as care partners for diabetes
affected individuals was a major impediment in the process of seeking necessary care
services and engaging in effective self-management. The researchers reported that most
people who act as good care partners for patients are typically grandchildren, friends,
siblings, parents, and partners. Presence of high emotional closeness with these partners was
facilitated by establishment of greater contact that included engaging in discussions at least
twice, each week. The research findings also helped in elucidating the fact that greater
emotional closeness with the aforementioned people was effective in increasing the
medication adherence, proper dietary consumption of fruits and vegetables, and reduced
distress due to diabetes, thus supporting absence of social closeness as a major hindrance to
diabetes care. Furthermore, presence of an in-home supporter was associated with a reduced
HbA1c level.
The impacts of social support were also elaborated by Ong, Chua and Ng (2014) and
Vest et al. (2013) who stated that diabetes patients often expressed a longing for better
understanding and compassion from their family members and medical providers. They did

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not consider diabetes education as sufficient for increasing their adherence to the treatment
regimen and screening services and stated that presence of some support worker or nurse, at
residences, often made them feel motivated for properly managing their health condition.
Hence, insufficient support and motivation from friends, family and healthcare providers
prevented patients with diabetes from seeking appropriate care services.
Educational attainment and socioeconomic condition of the patients
Summary of findings from the study conducted by Van Eijk et al. (2012) highlighted
the fact that people having higher educational attainment (91.6%) attended more number of
screening programs for diabetic retinopathy, in comparison to the 8.4% patient population
having low educational attainment. It was further stated that lack of education among the
patients typically resulted in absence of adequate awareness among them, in relation to
diabetes prevention and management, thereby acting as a major obstacle in attending
screening programs and accessing care services. The researchers also stated that presence of
financial barriers also preventing accessing diabetes care. This was congruent to Sina, Graffy
and Simmons (2018) who found that 372 patients with self-reported diabetes complications
reported their inability to afford necessary diabetes care services due to poor personal
finance.
The same was confirmed by Booth et al. (2013) who highlighted the fact that high
expenses of diabetic friendly diet often made it difficult for patients belonging to poor
socioeconomic condition to strictly show adherence to the treatment regimen, which
subsequently resulted in their failure in seeking necessary care facilities. It was further
illustrated by Hu et al. (2013) that poor patients with diabetes were often frustrated by the
absence of necessary resources and support from healthcare system, owing to their
unaffordability. Such patients do not typically have adequate money for buying medicines
needed to keep a check on their glycaemic control, and their low socio-economic and

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educational status also prevents them from obtaining medical attention. An analysis of the
findings presented by Mogre et al. (2019) suggested that most patients who are unable to
effectively participate in diabetes care strategies had attained poor levels of education or had
not been subjected to formal education.
Ong, Chua and Ng (2014) also highlighted that the costs of needles and test strips
were usually high that prevented patients from participating in activities that would allow
self-management of glucose levels, thereby suggesting that provisions for free needle and test
strip access would largely benefit patients in accessing diabetes care services. Hence, the
findings presented in the articles were successful in elaborating on the fact that
socioeconomic status of individuals directly affects their health status and access to
healthcare services. The lesser the situation in a hierarchy, the inferior is the health status of
the person. Hence, the evidences presented above suggested that poor economic condition
and lower levels of education made it difficult for patients diagnosed with diabetes to access
necessary care services and follow strict treatment regimen, which were often expensive. The
findings from Sina, Graffy and Simmons (2018) stated that patients often felt worried,
ashamed and afraid of the fact that they had been diagnosed with diabetes and displayed a
lack of willingness to care for themselves that acted as an impediment in the care seeking
process.
Psychosocial issues related to self-management of diabetes
A range of psychosocial issues were identified by Ong, Chua and Ng (2014) such as,
frustrations on observing high readings of blood glucose levels and stigma associated with
diabetes care. Responses from the patients suggested that they often considered diabetes self-
management as a challenge and felt apprehensive on not observing any noticeable reductions
in their blood glucose levels. They also felt depressed on carrying glucose meter along with
them all the time, which in turn prevented them from keeping a regular check on their

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glycaemic index. Furthermore, practicing diabetes self-management was also considered as a
stigma in presence of other individuals, besides the fear of pricking their finger with needles.
These statements were supported by Yasa et al. (2018) who stated that patients suffering
from diabetes often considered themselves as incapable of sufficiently managing their blood
glucose levels and had several apprehensions related to their disease. On the other hand, Vest
et al. (2013) illustrated that patients who displayed more trust in their doctors appeared more
probable to be content with the care they were getting for effective management of diabetes.
In addition, distrust on the healthcare providers were also found to result in ambivalence
towards clinical care, thereby insinuating at an interruption of an effective doctor-patient
association, which in turn had the potential to extremely obstruct effective diabetes
management. In the words of Mayberry et al. (2018) diabetes related distress that commonly
encompasses anxiety, depression, and self-management apprehensions were commonly
observed among adults affected with the metabolic syndrome and they were found to directly
affect the psychological wellbeing. On analysing the distress that the patients faced with the
use of Diabetes Distress Scale the researchers found that presence of an in-home diabetes
care supporter helped in the establishment of emotional proximity to the patients, and
subsequently brought about a reduction in the diabetes distress. Negative perceptions were
also associated with the modified food regimen, and routine rigidity that impeded the process
of seeking necessary diabetes care services (Booth et al. 2013). Psychosocial issues and
emotional hurdles were also recognised by Tong, Vethakkan and Ng (2015) who stated that
diabetes patients had an increased likelihood of manifesting signs and symptoms of
depression, and also reported that poor glycaemic control was accredited to personal
complications, which made them to feel nervous, stressed and unhappy, which caused them
to adopt unwholesome eating behaviours, and not taking necessary diabetes medications,
together with insulin. In addition, the fear of getting the finger pricked, while using a

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glucometer also made some patients show reluctance to perform regular glucose monitoring
(Mogre et al. 2019).

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Discussion
This chapter contains an overview of the overall themes and findings that have been
reported in the previous sections, and correlates them with theoretical perspectives that are in
accordance with the research phenomenon being investigated.
Prior to conducting this literature review, numerous gaps had been recognised, in
relation to the lack of adequate evidence on the primary challenges suffering from diabetes
encounter, while accessing medical care and information. Grol et al. (2013) highlighted the
fact that there are a plethora of behavioural factors that are concerned with the capability of
individuals to perform certain desired behaviour (diabetes self-care and management), which
in turn can be accredited to the fact that people typically have poor understanding and low
levels of awareness on the strategies that should be adopted for management of their blood
glucose levels. The fact that patients often lack necessary support and motivation for
effectively managing the metabolic condition can also be supported by several motivational
theories. These theories stress on the fact that motivation plays a crucial role in governing the
perceptions, attitudes, and intentions of individuals, towards an anticipated performance. The
theory of planned behaviour can be used to justify the statements that motivation acts as a
crucial factor that either encourages patients from showing adherence to healthy lifestyle
habits that are imperative to proper management of blood glucose levels (Montano and
Kasprzyk 2015). Hence, it can be suggested that presence of sufficient motivation and
support from peers and family members help in shaping the behavioural intentions of
diabetes patients towards their actions, in relation to access of care services.
Time and again it has been established that manifestation of attitudes concerning
particular behaviour (such as, access of care services and compliance to necessary strategies
for effective management of diabetes) is determined by the predictable consequences of the

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behaviour (such as, they will result in effective monitoring and maintenance of blood glucose
levels), and the constructive or undesirable effects of the outcomes (if the care service and
strategies are not worth the access or management strategies) (Ajzen 2015). It should also be
taken into account that there might be dissimilar motives, in relation to envisioning and
formulating for a particular change. For example, it has been established by Gao et al. (2013)
presence of social support and having greater amount of self-efficacy has been correlated
with better performance of diabetes self-management behaviours, which in turn are directly
associated with improved glycaemic control. Therefore, showing congruency with the studies
discussed in the literature review, it can be suggested that there is a need to formulate and
implement diabetes education programs to eliminate the barriers to diabetes care, and these
programs should comprise of approaches that focus on motivation, patient knowledge, and
behavioural skills for bringing about a behaviour change.
There is mounting evidence for the fact that inquisitiveness, financial wellbeing, and
pressure from family and colleagues often play an important role in shaping the behaviour of
a person (Farrell, Fry and Risse 2016). Hence, the target population must always have a clear
notion about the benefits that the change will involve, which in turn will maximise their
chances of participating in better self-management strategies. Taking into consideration the
fact that education and socioeconomic condition of the patients were found to play a decisive
role in the presence of diabetes care barriers, several educational theories are also in
accordance with the findings. The adult learning theory highlights the fact that persons are
able to learn better and feel an increased motivation for adapting to a change, under
circumstances when they ground their learning on different problems that have been
experienced in actual practice (Brockett and Hiemstra 2018). This can be further elucidated
by the findings presented by Healy et al. (2013) who elaborated on the fact that inpatient

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diabetes education (IDE) among diabetes patients was successful in lowering the rates of
hospital admissions within a month, in addition to a well maintained level of HbA1c.
Showing congruency with the articles discussed in the previous sections, disparities in
healthcare across different socioeconomic status of the patients play a substantial role in
disease management and access to care services. Research evidences have elaborated on the
fact that poor SES individuals display an increased likelihood of performing risky behaviour,
in comparison to their high SES counterparts that brings about a considerable deterioration in
their health outcomes (Chen and Miller 2013). In addition, wealth and income enable
acquisitions of healing and curative care services, thereby possibly allowing for restored
health maintenance. The effect of financial possessions on well-being and health is likely to
hinge on the scope of healthcare provisions in a republic. Taking into consideration the fact
that people belonging to poor socioeconomic strata of the society are often unable to access
the high-cost diabetes care services, and fail to adhere to a healthy lifestyle that requires
considerable expenditure, it can be suggested that higher wages allow the patients to accrue
larger wealth (Nobles, Weintraub and Adler 2013).
The findings can be further elaborated by utilising the Needs-Opportunity-Ability
(NOA) model that demonstrate the action of both external and internal factors on consumer
behaviour. According to this model, when opportunities and needs are combined into the
motivation of a subject to adequately perform an activity, a good outcome is generated
(Belafi, Hong and Reith 2018). Hence, combining the abilities and opportunities of the
patients will help them to gain better behavioural control and will also assist them in
accessing the care services that are imperative for effective diabetes management. The
perceived barriers to access of diabetes care services can also be explained by drawing
inferences from the Penchansky and Thomas's Theory of Access that focuses on the concepts
of accommodation, affordability, acceptability, accessibility, and availability. Time and again

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it has been stated that access to healthcare services encompasses the extent of fit between the
service and its user, thereby elaborating on the fact that more the fit, better is the access to the
services, which in turn is concomitant with improved health outcomes (Levesque, Harris and
Russell 2013). Sufficient access to diabetes care is of particular concern in remote and rural
regions due to barriers such as, small dispersed societies, socioeconomic disadvantage,
enormous distances and workforce scarcities. In addition, no healthcare services can prove
effective if it fails to address the concerns of the intended population. Hence, awareness and
mobility will ease the fit between services and patients, and assist them in manifesting active
care seeking behaviour.

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Conclusion
This chapter contains a summary of the evidences discussed by far, and draws
relevant conclusions from them, with the aim of adding substantial information to already
published evidences.
The term diabetes encompasses a range of metabolic conditions, which when
untreated, result in an abnormal elevation of blood glucose levels. Diabetes mellitus type 1
typically occurs under circumstances when the pancreas fail to synthesise sufficient amount
of insulin, which in turn can be accredited to an autoimmune destruction of the pancreatic
beta cells. The primary goal of diabetes management focuses on restoring the levels of
carbohydrate metabolism to standard levels. With the aim of accomplishing this goal, people
manifesting absolute deficiency of the hormone insulin often require the administration of
insulin therapy an also need to show adherence to healthy lifestyle habits. There are several
complexities associated with gaining proper access to healthcare amenities that facilitate self-
management of the metabolic condition. The management of diabetes is greatly intrusive and
adherence to prevention strategies becomes a major issue. The findings suggested that low
levels of educational attainment were responsible for increasing the proportion of unhealthy
habits among the patients, thereby increasing their susceptibility to the metabolic syndrome
and worsening their health condition. Education has been recognised as a major indicators of
the health outcomes such as, income, employment and social status, besides governing the
overall wellbeing of the patients. Therefore, those patients who lack awareness on the
prevention strategies and the services that are available in their community, encounter a range
of barriers to diabetes management.
Furthermore, it is likely that absence of social support and feelings of motivation
often make the patients more vulnerable to conditions that impede the process of accessing

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care services and also deteriorate the overall health and wellbeing of the target population.
Social support can be manifested in any form such as, appraisal, informational, instrumental
and emotional. The articles discussed in the literature review suggested that lack of display of
empathy, trust and love from the family members and/or peers, make it difficult for the
patients to adhere to diabetes management programs. Barriers in accessing diabetes care and
implementing self-management strategies also encompass a range of psychosocial issues that
comprise of depression, anxiety, and panic attacks. It was found that several patients report
apprehensions regarding the potential impacts of diabetes care services and were doubtful of
the effects that they would create on their blood glucose levels. Regular monitoring of blood
glucose levels and insulin therapy was also stereotyped by many, and patients often reported
feelings of embarrassment while participating in self-care strategies in front of others. In
addition, the findings also suggested that poor economic resources, and low levels of income
reduced the access to healthcare services, thereby worsening the health status.
Implications
The findings presented above will help in increasing awareness among the public on
the barriers to diabetes care and self-management, and will pave the way for formulation and
enforcement of policies that will allow all people residing in the UK, to access necessary
facilities. Dissemination of the findings will also allow implementing education campaigns
and social support among the target population. Future research should focus on determining
the efficacy of the education campaigns and policies in improving diabetes care.

24DISSERTATION
References
Ajzen, I., 2015. The theory of planned behaviour is alive and well, and not ready to retire: a
commentary on Sniehotta, Presseau, and Araújo-Soares. Health psychology review, 9(2),
pp.131-137.
American Diabetes Association., 2014. Diagnosis and classification of diabetes
mellitus. Diabetes care, 37(Supplement 1), pp.S81-S90.
Atlas, D., 2015. International diabetes federation. IDF Diabetes Atlas, 7th edn. Brussels,
Belgium: International Diabetes Federation.
Belafi, Z.D., Hong, T. and Reith, A., 2018. A critical review on questionnaire surveys in the
field of energy-related occupant behaviour. Energy Efficiency, pp.1-21.
Booth, A., 2016. Searching for qualitative research for inclusion in systematic reviews: a
structured methodological review. Systematic reviews, 5(1), p.74.
Booth, A.O., Lowis, C., Dean, M., Hunter, S.J. and McKinley, M.C., 2013. Diet and physical
activity in the self-management of type 2 diabetes: barriers and facilitators identified by
patients and health professionals. Primary health care research & development, 14(3),
pp.293-306.
Brockett, R.G. and Hiemstra, R., 2018. Self-direction in adult learning: Perspectives on
theory, research and practice. Routledge.
Chen, E. and Miller, G.E., 2013. Socioeconomic status and health: mediating and moderating
factors. Annual review of clinical psychology, 9, pp.723-749.
Deepa, M., Bhansali, A., Anjana, R.M., Pradeepa, R., Joshi, S.R., Joshi, P.P., Dhandhania,
V.K., Rao, P.V., Subashini, R., Unnikrishnan, R. and Shukla, D.K., 2014. Knowledge and
awareness of diabetes in urban and rural India: the Indian Council of Medical Research India

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diabetes study (phase I): Indian Council of Medical Research India diabetes 4. Indian journal
of endocrinology and metabolism, 18(3), p.379.
Diabetes.co.uk., 2018. Diabetes prevalence. [online] Available at:
https://www.diabetes.co.uk/diabetes-prevalence.html [Accessed 21 Feb. 2019].
Farrell, L., Fry, T.R. and Risse, L., 2016. The significance of financial self-efficacy in
explaining women’s personal finance behaviour. Journal of Economic Psychology, 54, pp.85-
99.
Gao, J., Wang, J., Zhu, Y. and Yu, J., 2013. Validation of an information–motivation–
behavioral skills model of self-care among Chinese adults with type 2 diabetes. BMC Public
Health, 13(1), p.100.
Grol, R., Wensing, M., Bosch, M., Hulscher, M. and Eccles, M., 2013. Theories on
implementation of change in healthcare. Improving patient care: The implementation of
change in health care, pp.18-39.
Healy, S.J., Black, D., Harris, C., Lorenz, A. and Dungan, K.M., 2013. Inpatient diabetes
education is associated with less frequent hospital readmission among patients with poor
glycemic control. Diabetes care, 36(10), pp.2960-2967.
Holt, T. and Kumar, S., 2015. ABC of Diabetes. John Wiley & Sons.
Hu, J., Amirehsani, K., Wallace, D.C. and Letvak, S., 2013. Perceptions of barriers in
managing diabetes: perspectives of Hispanic immigrant patients and family members. The
Diabetes Educator, 39(4), pp.494-503.
Kable, A.K., Pich, J. and Maslin-Prothero, S.E., 2012. A structured approach to documenting
a search strategy for publication: a 12 step guideline for authors. Nurse education
today, 32(8), pp.878-886.

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Kivimäki, M., Virtanen, M., Kawachi, I., Nyberg, S.T., Alfredsson, L., Batty, G.D., Bjorner,
J.B., Borritz, M., Brunner, E.J., Burr, H. and Dragano, N., 2015. Long working hours,
socioeconomic status, and the risk of incident type 2 diabetes: a meta-analysis of published
and unpublished data from 222 120 individuals. The lancet Diabetes & endocrinology, 3(1),
pp.27-34.
Levesque, J.F., Harris, M.F. and Russell, G., 2013. Patient-centred access to health care:
conceptualising access at the interface of health systems and populations. International
journal for equity in health, 12(1), p.18.
Macedo, A.F., Douglas, I., Smeeth, L., Forbes, H. and Ebrahim, S., 2014. Statins and the risk
of type 2 diabetes mellitus: cohort study using the UK clinical practice pesearch
datalink. BMC cardiovascular disorders, 14(1), p.85.
Mayberry, L.S., Piette, J.D., Lee, A.A. and Aikens, J.E., 2018. Out-of-home informal support
important for medication adherence, diabetes distress, hemoglobin A1c among adults with
type 2 diabetes. Journal of behavioral medicine, pp.1-9.
McBrien, K.A., Naugler, C., Ivers, N., Weaver, R.G., Campbell, D., Desveaux, L.,
Hemmelgarn, B.R., Edwards, A.L., Saad, N., Nicholas, D. and Manns, B.J., 2017. Barriers to
care in patients with diabetes and poor glycemic control—A cross-sectional survey. PloS
one, 12(5), p.e0176135.
McGowan, J., Sampson, M., Salzwedel, D.M., Cogo, E., Foerster, V. and Lefebvre, C., 2016.
PRESS peer review of electronic search strategies: 2015 guideline statement. Journal of
clinical epidemiology, 75, pp.40-46.
Menke, A., Casagrande, S., Geiss, L. and Cowie, C.C., 2015. Prevalence of and trends in
diabetes among adults in the United States, 1988-2012. Jama, 314(10), pp.1021-1029.

27DISSERTATION
Mogre, V., Johnson, N.A., Tzelepis, F. and Paul, C., 2019. Barriers to diabetes self‐care: a
qualitative study of patients’ and health care providers’ perspectives. Journal of clinical
nursing.
Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P. and
Stewart, L.A., 2015. Preferred reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement. Systematic reviews, 4(1), p.1.
Montano, D.E. and Kasprzyk, D., 2015. Theory of reasoned action, theory of planned
behavior, and the integrated behavioral model. Health behavior: Theory, research and
practice, pp.95-124.
Mumu, S.J., Saleh, F., Ara, F., Haque, M.R. and Ali, L., 2014. Awareness regarding risk
factors of type 2 diabetes among individuals attending a tertiary-care hospital in Bangladesh:
a cross-sectional study. BMC research notes, 7(1), p.599.
Nobles, J., Weintraub, M.R. and Adler, N.E., 2013. Subjective socioeconomic status and
health: relationships reconsidered. Social Science & Medicine, 82, pp.58-66.
Ong, W.M., Chua, S.S. and Ng, C.J., 2014. Barriers and facilitators to self-monitoring of
blood glucose in people with type 2 diabetes using insulin: a qualitative study. Patient
preference and adherence, 8, p.237.
Peters, M.D., Godfrey, C.M., Khalil, H., McInerney, P., Parker, D. and Soares, C.B., 2015.
Guidance for conducting systematic scoping reviews. International journal of evidence-
based healthcare, 13(3), pp.141-146.
Sina, M., Graffy, J. and Simmons, D., 2018. Associations between barriers to self-care and
diabetes complications among patients with type 2 diabetes. Diabetes research and clinical
practice, 141, pp.126-131.

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Stern, C., Jordan, Z. and McArthur, A., 2014. Developing the review question and inclusion
criteria. AJN The American Journal of Nursing, 114(4), pp.53-56.
Tong, W.T., Vethakkan, S.R. and Ng, C.J., 2015. Why do some people with type 2 diabetes
who are using insulin have poor glycaemic control? A qualitative study. BMJ open, 5(1),
p.e006407.
Usher, K.M., 2015. Valuing all knowledges through an expanded definition of
access. Journal of agriculture, food systems, and community development, 5(4), pp.109-114.
Van Eijk, K.N.D., Blom, J.W., Gussekloo, J., Polak, B.C.P. and Groeneveld, Y., 2012.
Diabetic retinopathy screening in patients with diabetes mellitus in primary care: incentives
and barriers to screening attendance. Diabetes research and clinical practice, 96(1), pp.10-
16.
Vest, B.M., Kahn, L.S., Danzo, A., Tumiel-Berhalter, L., Schuster, R.C., Karl, R., Taylor, R.,
Glaser, K., Danakas, A. and Fox, C.H., 2013. Diabetes self-management in a low-income
population: impacts of social support and relationships with the health care system. Chronic
illness, 9(2), pp.145-155.
Yasa, I., Rahayu, V.M., Widastra, I., Labir, I.K., Wedri, N.M. and Sulisnadewi, N.L.K.,
2018. Barrier of Self Care Management on Urban Type 2 Diabetic Patients in Bali. Indian
Journal of Public Health Research & Development, 9(5), pp.363-367.
Zeng, X., Zhang, Y., Kwong, J.S., Zhang, C., Li, S., Sun, F., Niu, Y. and Du, L., 2015. The
methodological quality assessment tools for preclinical and clinical studies, systematic
review and meta‐analysis, and clinical practice guideline: a systematic review. Journal of
evidence-based medicine, 8(1), pp.2-10.

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30DISSERTATION
Personal reflection
My emotional state and thoughts while conducting the dissertation underwent several
changes all through the course of the work. While conducting this curriculum assignment, I
had been assigned with the task of developing a framing a 20 pages dissertation. Originally, I
had the concept that the procedure would be extremely difficult, owing to my former
experience of just having analysed important qualitative and quantitative articles for a
research proposal, focusing on diverse health complications. Thus, I was completely not well
conversant with the technique of framing a thematic analysis. Hence, writing this dissertation
based on the previous research proposal was a different experience. I obtained sufficient
guidance from my guide and lecturers on the rubrics that need to be tracked while developing
the dissertation. However, this was the first time that I was writing a dissertation all by
myself, hence, I was extremely anxious of its outcomes. Therefore, creating the dissertation
based on thematic analysis review plan, turned out to be quite thought-provoking, than I
expected. I began bordering on the research question by identifying and delineating a design-
based examination of the proposal that I had already submitted. I had previously developed a
sequence of research in my cognizance, and how it could be amalgamated with the
construction of the design-based investigation. I encountered some challenges while
generating a brief and to the point research question, as per the formats that had been
discoursed in my class.
Subsequent to the development of the research question, I also encountered some
challenges in classifying the precise approach of literature search for the question. Narrowing
down the accurate search terms was an additional complex process that took up a substantial
amount of time. Having established a suitable research question, I gave a comprehensive read
of other methodical reviews that had been piloted on diabetes care, with the purpose of
understanding the procedure of distinguishing key terms that would aid in mining of pertinent

31DISSERTATION
articles. While citing the determination behind conducting the investigation, I had to hunt for
academic literature that could elucidate the difficulties related with diabetes care.
Additionally, the dissertation also required me to probe through the reports that had been
published in administration websites and diverse healthcare organisations that eased
identification of the extensive commonness of diabetes across the world and the UK.
Upon reflection, one of the main features due to which I kept on coming across
trouble was with the hypothetical framework. I found it problematic to understand the model
or philosophy that was allied with the occurrence being investigated. I also found it thought-
provoking to obtain satisfactory and up-to-date evidence on the Penchansky and Thomas’s
theory of access, for accumulating a sound explanation of the objectives and aims of the
proposal. I allowed myself the authorisation to find out the comprehensive and relevant
questions, and also requested for assistance from my guide for gaining descriptive responses
to those enquiries. A share of joy in this investigation was related with reckoning the
dissimilar methods that proved accommodating to me, for procurement of a detailed
clarification to my research question during the dissertation.

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Appendices