Research Article: Diabetes self-management in three different income settings: Cross-learning of barriers and opportunities

Date Published: March 19, 2019

Publisher: Public Library of Science

Author(s): Jeroen De Man, Juliet Aweko, Meena Daivadanam, Helle Mölsted Alvesson, Peter Delobelle, Roy William Mayega, Claes-Göran Östenson, Barbara Kirunda, Francis Xavier Kasujja, David Guwattude, Thandi Puoane, David Sanders, Stefan Peterson, Göran Tomson, Carl Johan Sundberg, Pilvikki Absetz, Josefien Van Olmen, Noël C. Barengo.


The burden of type 2 diabetes is increasing rapidly, not least in Sub-Saharan Africa, and disadvantaged populations are disproportionally affected. Self-management is a key strategy for people at risk of or with type 2 diabetes, but implementation is a challenge. The objective of this study is to assess the determinants of self-management from an implementation perspective in three settings: two rural districts in Uganda, an urban township in South Africa, and socio-economically disadvantaged suburbs in Sweden. Data collection followed an exploratory multiple-case study design, integrating data from interviews, focus group discussions, and observations. Data collection and analysis were guided by a contextualized version of a transdisciplinary framework for self-management. Findings indicate that people at risk of or with type 2 diabetes are aware of major self-management strategies, but fail to integrate these into their daily lives. Depending on the setting, opportunities to facilitate implementation of self-management include: improving patient-provider interaction, improving health service delivery, and encouraging community initiatives supporting self-management. Modification of the physical environment (e.g. accessibility to healthy food) and the socio-cultural environment (i.e. norms, values, attitudes, and social support) may have an important influence on people’s lifestyle. Regarding the study methodology, we learned that this innovative approach can lead to a comprehensive analysis of self-management determinants across different settings. An important barrier was the difficult contextualization of concepts like perceived autonomy and self-efficacy. Intervention studies are needed to confirm whether the pathways suggested by this study are valid and to test the proposed opportunities for change.

Partial Text

Non-communicable diseases (NCD) are strong contributors to poverty and inequity within and across countries, disproportionately affecting people of low socioeconomic status [1]. A recent series of articles in the Lancet launched a strong call for action against the burden of NCDs [2], directly in line with Sustainable Development Goal (SDG) 3·4 to reduce premature NCD mortality and indirectly in line with SDGs 1, 2, 4, 5, and 10 [1]. Type 2 diabetes (T2D) is a major contributor to the NCD burden. Similar to other NCDs, the global prevalence of diabetes in adults is increasing and is estimated to grow from 8·8% in 2015 to 10·4% in 2040 [3], with Sub-Saharan Africa contributing the largest share of this growth [3]. In high income countries (HICs), socio-economically disadvantaged populations and immigrants are disproportionately affected [4].

The SMART2D study aims for cross-contextual reciprocal learning in three cycles [13]. The studies in this paper describe the first learning cycle which had three steps. The first step was to build a conceptual framework that fosters a common understanding in the three settings throughout the SMART2D project. In a second step, this common framework was translated concurrently into a generic topic guide and site-specific focus group and interview guides (S1 and S2 Appendix). Site-specific data collection (focus groups, interviews, and observations) was carried out by each of the country teams and preliminary data-analysis was conducted. In a third step, each of the sites populated the themes of the generic topic guide that were applicable to their specific site, based on the data collected in the previous step and additional secondary data (i.e. national statistics, findings from other studies, and project documents). This data was synthesized in a table with cross-cutting themes and a core team assessed commonalities and differences in self-management and its influencing factors which forms the subject of this paper.

To our knowledge, this is the first study to explore self-management determinants of T2D among disadvantaged populations in three different settings through the use of a common guiding framework. Earlier studies on disadvantaged populations confirm the influence of psychological factors (e.g. knowledge, beliefs, behavioral skills, etc.)[33] and the individual’s socio-cultural context, including social support networks [34,35], and motivational support from health care providers [36]. However, those studies have not compared different contexts and had a narrow focus on a specific set of elements. Our data cover a comprehensive set of elements that play a role in the implementation of self-management including the individual and their family, health- and community actors, the health system, and the proximal environment. The study links these elements with self-management behavior through individual mediators.

The implementation of self-management relates to a complex interplay between the individual, the socio-cultural and physical environment, the health system, and related actors. Implementing self-management in a particular context will benefit from an overarching framework contextualized through a situation analysis. Essential is that such a framework not only identifies the necessary self-management support interventions, but also how these interventions need to be implemented. This can be obtained through consideration of the pathways linking the individual’s behavior with its proximal environment.




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