Connectivity,contest and the ties of self‐management support for type 2 diabetes: a meta‐synthesis of qualitative literature

This paper presents a meta‐synthesis of the literature on community‐based self‐management to support experiences of people diagnosed with type 2 diabetes. The aim was to synthesise findings on both formal and informal self‐management support with particular reference to the relevance and influence of the social context operating at different levels. The review forms part of EU‐WISE, a project financed through EU's 7th Framework Programme. The review was performed by systematically searching MEDLINE, PubMed, EMBASE, CINAHL, PsycINFO and Web of Science for English language publications between 2005 and 2014 presenting research conducted in Europe on the experiences and perspectives of self‐management concerns of patients diagnosed with type 2 diabetes. The search yielded 587 abstracts, which were reduced through search strategy refinement and eligibility and quality criteria to 29 papers that were included in the review. This review highlights the relevance of contextual factors operating at micro‐ and macro‐levels. The synthesis yielded six second‐order thematic constructs relating to self‐management: sense of agency and identity, the significance and meaning of social networks, minimal disruption of everyday life, economic hardship, the problem of assigning patients’ responsibility and structural influences of primary care. Using a line of argument synthesis, these themes were revisited, and a third‐order construct, connectivity emerged which refers to how links in daily life are interwoven with peoples’ social networks, local communities, economic and ideological conditions in society in a way which support self‐management activities. This meta‐synthesis indicates a need to heed the notion of connectivity as a means of mobilising and supporting the self‐management strategies of people with type 2 diabetes in everyday life.     

A systematic review of research into black and ethnic minority patients' views on self‐management of type 2 diabetes

Context

Eliciting patients'' views of type 2 diabetes self‐management provides insights on how policy and services might better support the needs of this population.

Objective

To synthesize black and ethnic minority patients'' views on the barriers and facilitators influencing the self‐management of type 2 diabetes.

Search strategy

A systematic search of international literature published in nine electronic databases was undertaken in 2008. Search strategies used both MeSH and free‐text terms. Two relevant journals were also hand searched.

Inclusion criteria

Any primary empirical study published in the English language since 1986 that reported black and ethnic minority patients'' views on type 2 diabetes self‐management.

Data extraction and synthesis

Data were extracted and study quality was formally assessed. Data were analysed using thematic synthesis.

Main results

Fifty‐seven studies were included, of qualitative (n = 54), mixed‐method (n = 2) or quantitative (n = 1) design. Studies were from North America (n = 41), Europe (n = 14) and Australia (n = 2), including 1735 participants in total. Three analytical themes emerged: ‘Importance of identity’; ‘Being understood by others’ and ‘Making sense of condition’, all linked conceptually under the overarching theme ‘Sense of self’. The quality of the studies varied.

Discussion and conclusions

The findings provide insight into what black and minority ethnic people regard as the barriers to, and facilitators of self‐management, as opposed to what health professionals, policy makers and trial researchers may have assumed. Recognition of the views of people with diabetes is essential for the design and delivery of patient‐centred care and policies.     

Health professionals’ experiences and perspectives on food insecurity and long‐term conditions: A qualitative investigation

Estimates suggest that over 10% of the UK population are affected by food insecurity. International evidence indicates that food insecurity is a risk factor for many long‐term health conditions, and can adversely affect people's ability to manage existing conditions. Food insecurity is thus not only a serious social concern but also a healthcare issue requiring the attention of UK health professionals. An exploratory qualitative study was undertaken to investigate the experiences and views of health professionals in north east Scotland, with a particular focus on support for people with long‐term conditions whom they believed were affected by food insecurity. Two focus groups and nine semi‐structured interviews were undertaken with a total of 20 health professionals between March and July 2016. Thematic analysis generated three main themes. The health professionals had (a) diverse levels of understanding and experience of food insecurity, but between them identified a range of (b) negative impacts of food insecurity on condition‐management, especially for diet dependent conditions or medication regimes, and for mental health. Even for those health professionals more familiar with food insecurity, there were various (c) practical and ethical uncertainties about identifying and working with food insecure patients (it could be difficult to judge, for example, whether and how to raise the issue with people, to tailor dietary advice to reflect food insecurity, and to engage with other agencies working to address food insecurity). This study indicates that health professionals working with food insecure patients have learning and support needs that warrant further investigation. Debates about health professionals’ responsibilities, and interventions to guide and support health professionals, including tools that might be used to screen for food insecurity, must also reflect the diverse lived needs and values of people who experience food insecurity.     

Enhancing health literacy and behavioural change within a tele‐care education and support intervention for people with type 2 diabetes

Background Behavioural change interventions for persons with chronic illness draw on a variety of theoretical approaches including motivational interviewing and shared decision making. Health literacy provides an additional, potentially powerful explanatory framework to guide research and practice. Objective To examine the changes in the depth and detail of diabetes‐related knowledge and confidence for persons with type 2 diabetes. Design Two‐year, prospective, observational study, using questionnaire data at two time points (baseline and 2 years later) and in‐depth interviews with a theoretically selected subsample. Setting and participants A total of 319 patients initially recruited from a deprived urban area in north‐west England Intervention Dedicated tele‐carer education and support, tailored to the individual circumstances of the patient. Main outcome measures Perceptions of confidence, levels of empowerment, learning for self‐care and most helpful aspects of the intervention. Results Over 90% expressed confidence in keeping their blood sugar controlled, and high levels of perceived empowerment (mean = 4.25; 95% CI, 4.17–4.33) were found. Changes in the depth and detail of diabetes‐related knowledge and confidence, from the specific to the more general, were observed and enhanced competence in translating knowledge into practice. Discussion and conclusions The intervention, built within a developed working partnership between tele‐carer and patient, operated at two levels: health literacy, enhancing knowledge, developing personal skills and enabling self‐control; and socio‐psychological behavioural change, tailored to individuals within their socio‐economic environments, enabling increased motivation and supportive problem‐solving. Both approaches find reflection in the findings and provide powerful explanatory lenses to interrogate the data.     

Challenges to developing diabetes self‐management skills in a low‐income sample in North Carolina,USA

High rates of diabetes diagnosis and poor diabetes outcomes are particularly significant in low‐income, socially disadvantaged populations. Although many social and economic predictors of poor self‐management outcomes are known, few studies have examined how these elements impact the ability to develop self‐management capacities in low‐income populations. This article presents new insights into low‐income women's challenges and successes to becoming more adept self‐managers. Interview data were collected in 2012 with a sample of low‐income, middle‐age women with type II diabetes recruited from a non‐profit medical clinic serving low‐income clients in North Carolina, United States. Data were analysed using a grounded theory approach. Developing self‐management skills within disadvantaged life contexts involved negotiating three related, overlapping sub‐processes: negotiating access to care systems, negotiating disruptions to diabetes self‐management patterns, and negotiating self‐care knowledge. Developing diabetes self‐management skills is a long and arduous process. Data and analysis presented here help explain how disadvantaged life contexts can impact self‐managers' efforts to develop self‐management skills and why continued support is important for reducing and preventing future problems. These initial findings suggest that future studies and intervention development on the topic are warranted.     

Patient–professional partnerships and chronic back pain self‐management: a qualitative systematic review and synthesis

Chronic back pain is common, and its self‐management may be a lifelong task for many patients. While health professionals can provide a service or support for pain, only patients can actually experience it. It is likely that optimum self‐management of chronic back pain may only be achieved when patients and professionals develop effective partnerships which integrate their complementary knowledge and skills. However, at present, there is no evidence to explain how such partnerships can influence patients' self‐management ability. This review aimed to explore the influence of patient–professional partnerships on patients' ability to self‐manage chronic back pain, and to identify key factors within these partnerships that may influence self‐management. A systematic review was undertaken, aiming to retrieve relevant studies using any research method. Five databases were searched for papers published between 1980 and 2014, including Cochrane Library, CINAHL, Medline, EMBASE and PsycINFO. Eligible studies were those reporting on patients being supported by professionals to self‐manage chronic back pain; patients being actively involved for self‐managing chronic back pain; and the influence of patient–professional partnerships on self‐management of chronic back pain. Included studies were critically appraised for quality, and findings were extracted and analysed thematically. A total of 738 studies were screened, producing 10 studies for inclusion, all of which happened to use qualitative methods. Seven themes were identified: communication, mutual understanding, roles of health professionals, information delivery, patients' involvement, individualised care and healthcare service. These themes were developed into a model suggesting how factors within patient–professional partnerships influence self‐management. Review findings suggest that a partnership between patients and professionals supports patients' self‐management ability, and effective communication is a fundamental factor underpinning their partnerships in care. It also calls for the development of individualised healthcare services offering self‐referral or telephone consultation to patients with chronic conditions.     

A qualitative exploration of responses to self‐compassion in a non‐clinical sample

Research suggests that being self‐compassionate can have myriad benefits, including life satisfaction, health‐promoting behaviours and improved mental health. Given the possible advantages of being self‐compassionate, it seems critical to explore how to promote this in the general population. This qualitative study aimed to understand responses to the idea of being compassionate to oneself within the general population. Semi‐structured interviews were conducted in the North East of England between October 2014 and February 2015, they were analysed using thematic analysis. As part of an intervention study, non‐clinical volunteers watched a psychoeducation video about the concept of self‐compassion and then participated in one of four meditation exercises. Following this, participants were interviewed about their responses to the idea of being self‐compassionate. Three themes were identified: Benefits of Self‐Compassion; Being Self‐Compassionate and Barriers to Self‐Compassion. Participants believed that being self‐compassionate would be beneficial, for both themselves and the world, but they believed that self‐compassion would make them vulnerable and that others would judge them. Thus, participants were afraid to be the first ones to be self‐compassionate and stated that, in order for self‐compassion to be acceptable, we need to change the perspective of western culture. These findings underscore the importance of understanding society's role in a person's ability to be self‐compassionate. In order to reap the benefits of self‐compassion, we need to create a culture that accepts and encourages this. As practitioners, we are in a position to lead in self‐compassion and to encourage other leaders to promote this as a preventative mental health strategy.     

People’s preferences for self‐management support

ObjectiveTo identify and assess the preferences of people with long‐term health conditions toward generalizable characteristics of self‐management support interventions, with the objective to inform the design of more person‐centered support services.Data SourcesPrimary qualitative and quantitative data collected on a representative sample of individuals with at least one of the fifteen most prevalent long‐term conditions in the UK.Study DesignTargeted literature review followed by a series of one‐to‐one qualitative semistructured interviews and a large‐scale discrete choice experiment.Data CollectionDigital recording of one‐to‐one qualitative interviews, one‐to‐one cognitive interviews, and a series of online quantitative surveys, including two best‐worst scaling and one discrete choice experiment, with individuals with long‐term conditions.Principal FindingsOn average, patients preferred a self‐management support intervention that (a) discusses the options available to the patient and make her choose, (b) is individual‐based, (c) face to face (d) with doctor or nurse, (e) at the GP practice, (f) sessions shorter than 1 hour, and (g) occurring annually for two‐third of the sample and monthly for the rest. We found heterogeneity in preferences via three latent classes, with class sizes of 41% (C1), 30% (C2), and 29% (C3). The individuals’ gender [P < 0.05(C1), P < 0.01(C3)], age [P < 0.05(C1), P < 0.05(C2)], type of long‐term condition [P < 0.05(C1), P < 0.01(C3)], and presence of comorbidity [P < 0.01(C1), P < 0.01(C3), P < 0.01(C3)] were able to characterize differences between these latent classes and help understand the heterogeneity of preferences toward the above mentioned features of self‐management support interventions. These findings were then used to profile individuals into different preference groups, for each of whom the most desirable form of self‐management support, one that was more likely to be adopted by the recipient, could be designed.ConclusionsWe identified several factors that could be used to inform a more nuanced self‐management support service design and provision that take into account the recipient''s characteristics and preferences.