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Question Are patient and provider perspectives on the management of type 2 diabetes mellitus similar for issues of control, goal setting, evaluation of success, and treatment strategies?
Design
Qualitative, exploratory study.
Setting
Public clinics and community health centres in Texas, USA.
Participants
51 Mexican-American adults who had diabetes for >1 year and no major diabetes related impairment (mean age 52.9 y, 51% men, and mean annual household income US$12 500) and 35 practitioners (26 physicians, 5 physician's assistants, 2 nurse practitioners, and 2 staff nurses) who had direct patient care responsibilities (mean age 43.3 y, 71% men, and 51% Hispanic).
Methods
Patients were interviewed in their homes using semi-structured questions on illness history, coping strategies, perceived barriers to care, the illness, and its management. Practitioners were interviewed with emphasis on treating diabetes (attitudes, difficulties, and how to deal with the difficulties). Interviews were taped, transcribed, indexed, cross checked, and data were categorised into goals, evaluation, and strategies for dealing with diabetes.
Main findings
The goal of patients was to integrate the control of their diabetes into daily life. This involved an emphasis on behaviour control more than glucose control. Practitioners' goals were two-fold: to achieve control over glucose concentrations and to induce patients to control their self care behaviours (diet, medication, and exercise), using instruction and motivation.
To evaluate the success of their disease management, patients did not rely primarily on glucose concentrations, but were more concerned with how well they felt and how well they were able to maintain their normal activities. For practitioners, success was based on blood glucose concentrations (glycated haemoglobin or fasting glucose concentrations). They also felt that poor glucose concentrations implied poor behaviour control by patients.
For patients, strategies of care involved the broad construct of
taking care of myself. This included control of diabetes and self control and necessitated the balance of diabetes with other competing life factors. Practitioners emphasised the importance of self care behaviours and the challenges of getting patients to make lifestyle changes. Patient education and nutrition counselling were their main strategies. Some practitioners felt frustrated and used threats, negotiation, and scenarios to scare patients.
For patients, failed treatment prompted either increased vigilance or abandonment. Their poor financial situation caused patients to fear job loss if employers knew about their disease and to worry about treatment costs. Some practitioners felt that cultural factors were more important than financial factors, some ignored finances altogether, and some could not find ways to integrate this into treatment approaches.
Conclusion
Patients focused on integrating control of their diabetes into their daily lives, whereas practitioners focused more on glucose control.
Commentary
This study provides a comprehensive, comparative view of the perspectives of patients with type 2 diabetes and practitioners who treat diabetes. Patients were concerned with the experiential and social aspects of living with diabetes, particularly balancing and managing the integration of diabetes and lifestyle activities, whereas practitioners were occupied with physiological control. These findings are consistent with Hernandez' theory of integration1 and with subsequent studies of types 1 and 2 diabetes.
The study findings provide important insights about how patients with type 2 diabetes experience and interpret some of their daily challenges. These findings point to the need for all practitioners to review their practice expectations and delivery methods, and to enhance their empathy with their patients. Some caution, however, should be exercised in generalising these results to dissimilar practice situations; the study patients were fairly well controlled, low income Mexican-Americans. Only 12% of the practitioners were nurses; therefore, the findings may be more consistent with the views of physicians rather than nurses. More research is needed to further explicate nurses' views of type 2 diabetes.
The researchers point out an additional “blind spot” of practitioners: they tended to presume the efficacy of the prescribed diabetes regimen in achievement of glycaemic control. The assumption that adherence leads to glycaemic control is simplistic and not generally supported by evidence. Researchers recommend the formation of collaborative alliances with patients as a partial solution to this problem. Practitioners who form collaborative alliances with patients can learn from their experiences and develop a deeper understanding of the complex decisions that must be made daily, within a context of many constraints. The development of collaborative alliances can help to address psychosocial as well as physiological concerns and includes the patient as a co-expert.2
Footnotes
Sources of funding: Texas Diabetes Institute and the Mexican American Medical Treatment Effectiveness Research Center.
For correspondence: Dr Linda M Hunt, School of Nursing, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX 78284, USA. Fax +1 210 567 5822.