VOLUME 11 NUMBER 2 • JUNE 2014
61
SA JOURNAL OF DIABETES & VASCULAR DISEASE
RESEARCH ARTICLE
Correspondence to: Nneka C Onwudiwe
Pharmaceutical Health Services Research, University of Maryland School of
Pharmacy, Baltimore, Maryland, USA
Tel: 410-706-0908
Fax: 410-706-5394
e-mail:
C Daniel Mullins, Faida T Shaya, Francoise G Pradel
University of Maryland School of
Pharmacy, Department of Pharmaceutical
Health Services Research, Baltimore, Maryland, USA
Reed A Winston, Aurelia Laird
Bon Secours, Baltimore Health Systems, Baltimore, Maryland, USA
Elijah Saunders
Department of Medicine, Division of Cardiology, University of Maryland
School of Medicine, Baltimore, Maryland, USA
Originally published in
Ethnicity Dis
2011;
21
: 27–32.
S Afr J Diabetes Vasc Dis
2014;
11
: 61–65
Barriers to self-management of diabetes: a qualitative study
among low-income minority diabetics
NNEKA C ONWUDIWE, C DANIEL MULLINS, REED A WINSTON, AIDA T SHAYA, FRANCOISE G PRADEL,
AURELIA LAIRD, ELIJAH SAUNDERS
Abstract
Objectives:
Diabetes self-management is a key element in
the overall management of diabetes. Identifying barriers
to disease self-management is a critical step in achieving
optimal health outcomes. Our goal was to explore patients’
perceptions about barriers to self-management of diabetes
that could possibly help explain poor health outcomes
among minority patients.
Study design:
Four focus groups were conducted among 31
predominately African-American patients with diabetes who
were enrolled in the Baltimore Cardiovascular Partnership
Study, aNIH-fundedmulti-year prospective partnership study.
The topic guide consisted of a series of open-ended questions
about knowledge of current health status, medication use,
continuity of care, blood glucose level and nutrition.
Results:
The focus groups confirmed that previously reported
barriers to self-management persisted, and identified
new concerns that could be associated with poor health
outcomes among minority patients with diabetes. Attitudes,
perceptions and behaviours surrounding diabetes and self-
management of the condition did vary across individuals,
however, the variation appeared to reflect the individual’s
knowledge and opinions rather than patient’s age, gender
or culture. The primary barrier to diabetes self-management
resulted from lack of knowledge of target blood glucose
level and blood pressure. Several participants found some of
the health information quite confusing.
Conclusions:
Diabetes is a major public health concern and
the lack of awareness of target blood glucose level and
blood pressure further complicates the problem. The limited
health literacy seen in this study could help explain several
of the barriers to self-management. The barriers to self-
management identified in this qualitative study are amenable
to intervention that could improve health outcomes.
Keywords:
diabetes, self-management, barriers
Introduction
Diabetes is the fifth leading cause of death by disease in the
United States.
1
The burden of diabetes disproportionately affects
minorities. The prevalence of diabetes is about 11% in African-
Americans and 8% in Caucasians and is about twice as prevalent
in African-American females (14%) as in Caucasian (7%) females.
2
The incidence of type 2 diabetes is four times higher for African-
Americans than for non-Hispanic whites.
3
Genetic and lifestyle
factors, such as history of gestational diabetes, excessive food
consumption and physical inactivity, are likely to account for the
increased prevalence of type 2 diabetes among ethnic minorities.
4
Numerous studies have documented a higher prevalence of
insulin resistance in minority groups after controlling for diabetes,
obesity and lifestyle factors.
5-7
Socioeconomic factors such as income
may also play a role in the increasing prevalence of diabetes and
diabetes related complications.
4,8
Socioeconomic status (SES) is a determinant of health and
a significant contributor to health disparities.
9,10
Typically, SES is
associated with poorer access to healthcare; however, healthcare
access and utilisation among diabetics is high.
11
Yet despite the
high rates of healthcare access and utilisation among diabetics,
health status and outcomes seen in low-income minorities is
unsatisfactory.
12-14
One possible explanation for the poor health
outcomes among patients with diabetes is poor self-management
practices.
11,15-18
Poor adherence to standard diabetes care recommendations
is associated with adverse outcomes in clinical practice.
13,14
Suboptimal adherence to standard diabetes care recommendations
is frequently observed in patients who have poor communication
with their provider, lack of understanding/knowledge of the
disease, polytherapy, suboptimal self-monitoring of blood glucose
levels and psychosocial factors such as depression.
14-24
Suboptimal adherence, once viewed as a patient problem, is
now seen as an indication of patients’ self-management of chronic
disease within the interactive framework of providers, healthcare
systems, families and communities.
25
Within this framework, the
dynamic interaction of patient, healthcare providers and systemic
factors can influence the overall management of diabetes.
26
The care
of patients with diabetes has largely encompassed new and more
efficacious diabetic treatments and improved medication delivery
systems,
27
but literature highlights the importance of integrating
self-management education.
26,28-33
To adequately address barriers
to diabetes self-management and identify strategies to overcome
them, it is important to examine whether there are additional
barriers that still exist.
