Exploring the barriers and facilitators of dietary self-care for type 2 diabetes: a qualitative study in Ghana

Introduction

Diabetes is a serious chronic, non-communicable disease whose prevalence has been on the ascendancy worldwide. In 2017, an estimated 15.5 (9.8-27.8) million adults were living with the disease in sub-Saharan Africa (SSA) with a regional prevalence of ̴ 6%. By 2045, this number is expected to increase by 162.5%, with an estimated 40.7 million suffering from type 2 diabetes (T2D).¹ The growing prevalence of diabetes in SSA, which is expected to outstrip all other global regions has been linked to behavioural factors, including ageing populations, increasing levels of obesity, physical inactivity, poor dietary habits as well as limited health and social care resources for tackling the disease.^2-4

In Ghana, the number of adults estimated to be living with diabetes in 2017 was 518.4 thousand with a country prevalence of ̴ 3.6% and associated health care costs of US$55.2 million. This number is expected to increase to 1426.3 million by 2045 with costs rising to US$132.9 million.¹ Studies in the general population have estimated a diabetes prevalence of between 6% and 9% among the adult population in urban areas with rural areas experiencing a lower prvalence.⁵ Factors such as an ageing population and improved socio-economic status; as well as interactions between acculturation, urbanization, and genetic disposition have all been cited as contributing towards this prevalence.^1,6.7

Although the past few decades have witnessed the development of novel drugs that play a key role in the clinical management of T2D, research has suggested that self-care behaviours involving the patient working in collaboration with health care providers to engage in health promotion activities such as diet, physical activity are also important.^8,9 Engaging in diabetes self-care is often recognized as the gateway to maintaining the health of diabetes patients, as effective self-management is not only useful for improving glycemic control, but it may also prevent diabetes-related complications, hospitalization and mortality.^10,11 Despite health professionals’ role in facilitating and supporting health education and promotion activities for diabetes self-care, the responsibility of inducing lifestyle changes for maintaining health ultimately rests with the patient and can be challenging to achieve in practice.

Understanding the factors that create barriers or facilitate diabetes self-care is important in developing appropriate educational materials and prioritizing interventions that empower individuals to better take care of themselves. A large number of qualitative studies have examined barriers and facilitators of diabetes self-care in high income countries.-¹⁴ with few studies exploring such phenomena in SSA countries.^15,16 Although some studies in Ghana have examined the level of adherence and factors associated with self-care behaviors in T2D patients and found patients’ demographic characteristics (e.g., age, gender, education, and religion) diet and body weight as significant shaping influences on behaviours,^17,18 much less attention has focused on the day-to-day challenges patients face and the facilitating factors in the management of the disease. In the last few years, controlling chronic, non-communicable diseases including diabetes has increasingly become a priority area in national health polices of many of many SSA countries¹⁹ and following this trend, Ghana’s Ministry of Health (MOH) has since 2012, developed a non-communicable disease policy and established centres that provide epidemiological evidence to guide national diabetes strategies.⁵ Against this background of increased policy interest in diabetes care and control, not much is known about patient’s and health provider’s (HP’s) views about lifestyle self-management. Such research is important in order to identify areas that require further improvement regarding patient counselling for promoting better health outcomes in diabetic patients.

The aim of this qualitative study was to explore the barriers and facilitators of T2D self-management from the perspectives of patients and HPs in Ghana.

Materials and Methods

Data collection

Data collection took place over a period of six months in 2015. Two major methods-non-participant observation and in-depth interviews were triangulated to obtain more reliable information from participants. Observation of patients and HPs took place over a period of 8 weeks, lasting over 1400 hours using an observation checklist and field note-taking, which were later expanded to provide more descriptive accounts of the events observed. The data gathered focused on the counselling process, including patients’ time of arrival at the out-patient’s department, waiting times, the nature of care provided and prevailing atmosphere. This technique was found valuable because it provided the opportunity to understand the variety of information given to patients regarding diet, how dietary education took place in terms of presentation, language and models; and patients’ reactions to this.²² In-depth semi-structured interviews were also conducted with HPs and patients based on a topic guide using the socio-ecological model (SEM),²³ which holds that certain behaviors of individuals might be shaped by their cultural beliefs, knowledge, preferences, the context of diabetes clinic, access to social support and cost (Figure 1). Some examples of questions for HPs were: “What type of dietary and physical activity advice do you offer?”, “How well do know patients adhere to T2D advice?”, What do you think are some of the barriers/challenges to diabetes self-care?”, What do you think are some of the things that make self-care easy?”. Interview questions for patients included: “When it comes to what to eat, do you experience any challenges?”, “Is it difficult to follow the advice given by the HP sometimes? Interviews, which lasted between 45-55 minutes were conducted in a quite location of the hospital provided by the HPs. It provided participants with an environment to speak freely and openly about their experiences. A flexible approach to interviewing was adopted using follow-up questions, probes and comments to gain greater insight into participants’ views about diabetes self-care.²⁴ Data saturation (i.e. where no new perspectives on the subject were being elicited) was achieved after conducting 33 interviews and this was confirmed with the last three study participants. Informed consent was obtained from all participants.

Figure 1

Socio-ecological behavioural model.

Results

Discussion

This study aimed to explore the barriers and facilitators of T2D self-management among adult patients attending a specialist diabetes clinic in Accra, Ghana. Findings from observations, patients’ and HPs’ perspectives were similar to prior studies regarding diabetes management²⁶ specifically, and chronic conditions more generally.²⁷ The findings highlighted not only facilitators and barriers to T2D management during the counseling process and contexts of providing care, but also- related recommend food and diet regimens; social factors and patients’ hopes and fears about the disease. The findings support other studies that have attempted to understand and address the challenges of working within adult diabetic populations.^28-30 Moreover, while most studies in Ghana to date have focused essentially on factors such as patients’ demographic characteristics (e.g., age, gender, education, and religion) diet and body weight that are associated with adherence to recommended self-care behaviours^17,18; few qualitative studies have been undertaken to explore the multiple facilitators and barriers pertinent to the self-care of T2D. This study therefore adds to the rather sparse literature in this area. Although the facilitators and barriers to care more generally, have been discussed in the literature, what became clear in the data analysis was the extent to which diabetes care was dependent on the dynamic interaction between factors associated with the counselling process and context, recommended food and diet regimens, social context of managing the disease; as well as the hopes and fears about the disease as described next.

Regarding the counselling process and context, key facilitators included HPs’ role in helping patients to assume responsibility and control over their diabetes, patient acceptance of the diagnosis and rapport. Patient education, acceptance of diagnosis and motivation to engage in self-management in the context of patient-provider relationship have been cited previously.^14,31 However, in order to effect the most beneficial lifestyle changes, patients must be actively involved as experts and health care providers as advisors during the care and counselling process,³² similar to this study’s findings.

Rapport has been increasingly recognized as an important facilitator of T2D self-care.^33,34 Patients reported that HPs’ use of the local language in diabetes education facilitated trust and rapport in their relationship and motivated continued attendance at the clinic as well as compliance within care regimens. This finding implies that language barrier could hamper effective T2D self-management as some authors have suggested³⁴ and hence, tailoring diabetes interventions according to the language of the patient, especially in multi-ethnic societies, such as Ghana and other SSA countries can contribute to more effective self-management behaviours and practices.³⁵

Moreover, HPs reported barriers of patients not keeping follow-up appointments, while patients identified long waiting times and lack of acceptance of diagnosis as barriers. The tendency for patients to miss follow-up visits could be attributed to time constraints, lack of symptoms, long waiting times and high cost of consultation as reported in other studies.^36,37 The issue of cost of consultation is probably due to the fact that patients must pay out-of-pocket because the private specialist hospital of this study is not a registered service provider of Ghana’s National Health Insurance Scheme established to provide universal health coverage for the citizenry. These findings suggest that interventions to improve follow-up visits need to focus on educating patients about the importance of regular check-ups as well as other strategies designed to tackle multiple barriers simultaneously (e.g., to reduce out-of-pocket payments, quicker consultations), may be more effective in reducing non-attendance than strategies that target one barrier.²⁶ In addition, the few patients reporting a lack of acceptance of their diabetes, and hence lack of motivation to engage in self-care identified as a barrier, has been associated with the disease’s asymptomatic nature, perceived seriousness and fears of potential death resulting from the condition.³⁸ Previous studies also highlight the strong emotional distress and depression recognizable in diabetic patients that poses a significant barrier to self-care,³⁹ and for patients in this study, treatment might be complicated by limited access to mental health services - that is characteristic of low resources settings, including most SSA countries.⁴⁰ Some diabetes self-care programs have been shown to be effective in decreasing diabetes-related anxiety and distress in disadvantaged populations, and might be models to replicate in low resource settings.⁴¹ In relation to recommended food and diet regimens, barriers to lifestyle change received more prominence in patients’ accounts than facilitating factors. Mostly, patients’ concerns were about changing well-established habits, a general dislike of many aspects of their recommended diets and confusion about how to deal with particular aspects of the diet-factors which have been documented in previous studies.^28,42 Although, most patients in this study seemed to have some broad knowledge about the importance of diet in diabetes management, they appeared to be ill-equipped with specific information regarding recommended diets (e.g., acceptable types, quantities or amounts) that could help them to effect needed lifestyle changes. This lack of knowledge thus constituted a significant source of frustration for most patients trying to adjust to new diet regimens. While knowledge acquisition by patients during the diabetes care process is considered important for effective self-management, available evidence suggests that such knowledge might not be consistently applied in practice⁴³ as this study found. Increasingly, it has been suggested that tailored guidance based on individual needs and the provision of diet-specific information, previously shown to be effective in patients’ goal setting behaviors and habit modification practices should be the central focus of diabetes counselling.⁴⁴

Concerning social functions, most participants were of the perception that such occasions interfered with dietary alterations needed for effective diabetes care. This often resulted in patients reducing or avoiding some interactions with family and friends involving food and drinks. This means that patients in this study found a more positive disposition towards problem-solving and more rational decision-making towards controlling their diabetes. The exhibit of resiliency in diabetes care, such as found in this study, is consistent with other studies in New England and Iowa (US) among diabetes patients, in which those in better control of the disease; a) took diabetes more seriously; b) knew diet management was important; and c) viewed lifestyle changes as central to controlling diabetes.^34,45 This finding also supports another qualitative study in Germany, which found that people with T2D often experience an intense moral pressure to give up many pleasures and live a life of abstinence from certain foods in order to better control the disease - and suggest that taking into account this moral pressure, and patients’ personal efforts and strategies to establish healthy behaviours, might help to build better and trusting patient-provider relationships.⁴⁶

Moreover, patients’ family and social ties either facilitated or hindered self-care; for example, some family members assisted the patient with preparing recommend meals, while others diverted the patient from their goals regarding diet. The importance of family and friends as facilitators or barriers has been reported in previous research.^14,31 This implies that rather than simply focusing on technical issues, such as diet management, physical activity and glycemic control during the counselling process, providers could also educate patients on the role of family members and friends in shaping self-management. This is particularly important in Ghanaian and other African societies where strong emphasis is placed on family relationships as an enduring cultural value. However, this study, found limited focus on the role of such family interactions in diabetes-self-care during patient counselling sessions. The reason for this tendency is not clear. It might be because providers were often overwhelmed by the large number of patients attending the diabetes clinic in a particular day, and as such, tended to focus more on the technical aspects of managing the disease to the exclusion of its social dimensions. Greater clarity is needed to guide action.

Patients’ hopes and fears as positive or negative emotional responses to the diagnosis and as barriers to or facilitators of on-going self-management of T2D have been increasingly recognized.^47,48 A finding was that patients relied on a combination of bio-medicine, religion and belief in God to help with diabetes self-management. This is consistent with other literature on diabetes self-care among African Americans.¹² Other research reinforces the importance of religion and belief in God for diabetes management especially, in medically pluralistic health care settings, including SSA countries, where people engage in “health shopping” (i.e., using different medical systems either concurrently or successively) in times of ill-health.⁴⁹ Importantly, these studies have suggested that faith in God can be a major source of support as well as a major barrier in diabetes self-care. In this study, fear of diabetes made it difficult for patients to disclose the diagnosis to family members and/or pretended to be well, and adhere to dietary guidelines and medications more generally, in the belief that God would take care of them, such that it was not necessary to worry about their diabetes. This signifies a sense of fatalism, which has been associated with diabetes self-management among African Americans, suggesting that the diabetes was beyond their control.⁵⁰ This finding reinforces a range of strong emotional responses (e.g., fear, sadness, anxiety, depression) and hopes associated religious beliefs and practices influencing self-management that HPs should consider as part of providing patient-centered care for better outcomes.

Conclusion

Adults with T2D face many inter-related challenges to diabetes self-care than enabling factors around four major themes: These are: 1) the counselling process and context (patients missing follow-up appointments, unacceptance of diagnosis); 2) recommended food and diet regimens (changing longstanding dietary habits, dislike and confusion about recommended diets); 3) social aspects (social functions interfering with recommended dietary regimens, family members diverting patient from dietary goals) and 4) fears (non-disclosure to family member/pretense of being well). Integrated self-management interventions are needed to address these barriers. These include tailoring dietary education to specific needs of the patient, guiding patients on how to manage their diabetes during social occasions and among family members and friends; and providing mental health support for handling strong emotional reactions to the disease.

Ethical approval

Ethical clearance (RPN005/CSIR-IRB/2014) was obtained from the Institutional Review Board of the Council for Scientific and Industrial Research in Accra, Ghana. Informed consent was obtained from all study participants.

Competing interests

None declared.

Funding

No funding was received for the study.

Author’s contribution

MH conceived the study, collected, analyzed and interpreted the data; and drafted the manuscript.

Acknowledgments

The author thanks the study participants for their time and support.

References

1. International Diabetes Federation (IDF). Diabetes Atlas 8th Edition 2017. Available from: https://www.idf.org/component/attachments/?task=download&id=1525:Atlas-8e-Global-factsheet. Accessed June 19, 2019.
2. Agyemang C, Meeks K, Beune E, Owusu-Dabo E, Mockenhaupt FP, Addo J, et al. Obesity and type 2 diabetes in sub-Saharan Africans - Is the burden in today’s Africa similar to African migrants in Europe? The RODAM study. BMC Med 2016;14(1):166. doi: 10.1186/s12916-016-0709-0. [Crossref]
3. BeLue R, Okoror TA, Iwelunmor J, Taylor KD, Degboe AN, Agyemang C, et al. An overview of cardiovascular risk factor burden in sub-Saharan African countries: a socio-cultural perspective. Global Health 2009;5:10. doi: 10.1186/1744-8603-5-10. [Crossref]
4. Dagogo-Jack S, editor. Diabetes mellitus in developing countries and underserved communities. Switzerland: Springer International Publishing; 2017.
5. Ministry of Health (MOH). National Policy for the Prevention and Control of Chronic Non-Communicable Diseases in Ghana August 2012. Ghana: MOH; 2012.
6. Danquah I, Bedu-Addo G, Terpe KJ, Micah F, Amoako YA, Awuku YA, et al. Diabetes mellitus type 2 in urban Ghana: characteristics and associated factors. BMC Public Health 2012;12:210. doi: 10.1186/1471-2458-12-210. [Crossref]
7. Nsiah K, Shang VO, Boateng KA, Mensah FO. Prevalence of metabolic syndrome in type 2 diabetes mellitus patients. Int J Appl Basic Med Res 2015;5(2):133-8. doi: 10.4103/2229-516x.157170. [Crossref]
8. Shrivastava SR, Shrivastava PS, Ramasamy J. Role of self-care in management of diabetes mellitus. J Diabetes Metab Disord 2013;12(1):14. doi: 10.1186/2251-6581-12-14. [Crossref]
9. Habib F, Durrani AM. Self-care behaviour and well-being of diabetic patients. Indian Journal of Health and Wellbeing 2015;6(12):1268-71.
10. Adeloye D, Ige JO, Aderemi AV, Adeleye N, Amoo EO, Auta A, et al. Estimating the prevalence, hospitalisation and mortality from type 2 diabetes mellitus in Nigeria: a systematic review and meta-analysis. BMJ Open 2017;7(5):e015424. doi: 10.1136/bmjopen-2016-015424. [Crossref]
11. Rosano GM, Vitale C, Seferovic P. Heart failure in patients with diabetes mellitus. Card Fail Rev 2017;3(1):52-5. doi: 10.15420/cfr.2016:20:2. [Crossref]
12. Byers D, Garth K, Manley D, Chlebowy DO. Facilitators and barriers to Type 2 diabetes self-management among rural African American adults. J Health Dispar Res Pract 2016;9(1):164-74.
13. Joo JY, Lee H. Barriers to and facilitators of diabetes self-management with elderly Korean-American immigrants. Int Nurs Rev 2016;63(2):277-84. doi: 10.1111/inr.12260. [Crossref]
14. Dao J, Spooner C, Lo W, Harris MF. Factors influencing self-management in patients with type 2 diabetes in general practice: a qualitative study. Aust J Prim Health 2019;25(2):176-84. doi: 10.1071/py18095. [Crossref]
15. Worku A, Mekonnen Abebe S, Wassie MM. Dietary practice and associated factors among type 2 diabetic patients: a cross sectional hospital based study, Addis Ababa, Ethiopia. Springerplus 2015;4:15. doi: 10.1186/s40064-015-0785-1. [Crossref]
16. Habte BM, Kebede T, Fenta TG, Boon H. Barriers and facilitators to adherence to anti-diabetic medications: Ethiopian patients’ perspectives. Afr J Prim Health Care Fam Med 2017;9(1):e1-e9. doi: 10.4102/phcfm.v9i1.1411. [Crossref]
17. Frank LK, Kröger J, Schulze MB, Bedu-Addo G, Mockenhaupt FP, Danquah I. Dietary patterns in urban Ghana and risk of type 2 diabetes. Br J Nutr 2014;112(1):89-98. doi: 10.1017/s000711451400052x. [Crossref]
18. Mogre V, Abanga ZO, Tzelepis F, Johnson NA, Paul C. Adherence to and factors associated with self-care behaviours in type 2 diabetes patients in Ghana. BMC Endocr Disord 2017;17(1):20. doi: 10.1186/s12902-017-0169-3. [Crossref]
19. Kengne AP, Mayosi BM. Readiness of the primary care system for non-communicable diseases in sub-Saharan Africa. Lancet Glob Health 2014;2(5):e247-8. doi: 10.1016/s2214-109x(14)70212-8. [Crossref]
20. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005;15(9):1277-88. doi: 10.1177/1049732305276687. [Crossref]
21. Etikan I, Musa SA, Alkassim RS. Comparison of convenience sampling and purposive sampling. American Journal of Theoretical and Applied Statistics 2016;5(1):1-4. doi: 10.11648/j.ajtas.20160501.11. [Crossref]
22. Spradley JP. The Ethnographic Interview. Long Grove, Illinois: Waveland Press; 2016.
23. Glanz K, Rimer BK, Viswanath K. Health behavior and health education: theory, research, and practice. John Wiley & Sons; 2008.
24. DeJonckheere M, Vaughn LM. Semistructured interviewing in primary care research: a balance of relationship and rigour. Fam Med Community Health 2019;7(2):e000057. doi: 10.1136/fmch-2018-000057. [Crossref]
25. Fade SA. Communicating and judging the quality of qualitative research: the need for a new language. J Hum Nutr Diet 2003;16(3):139-49.
26. Grant RW, Kirkman MS. Trends in the evidence level for the American Diabetes Association’s “Standards of Medical Care in Diabetes” from 2005 to 2014. Diabetes Care 2015;38(1):6-8. doi: 10.2337/dc14-2142. [Crossref]
27. Wiley JA, Rittenhouse DR, Shortell SM, Casalino LP, Ramsay PP, Bibi S, et al. Managing chronic illness: physician practices increased the use of care management and medical home processes. Health Aff (Millwood) 2015;34(1):78-86. doi: 10.1377/hlthaff.2014.0404. [Crossref]
28. Laranjo L, Neves AL, Costa A, Ribeiro RT, Couto L, Sá AB. Facilitators, barriers and expectations in the self-management of type 2 diabetes--a qualitative study from Portugal. Eur J Gen Pract 2015;21(2):103-10. doi: 10.3109/13814788.2014.1000855. [Crossref]
29. Stephani V, Opoku D, Beran D. Self-management of diabetes in Sub-Saharan Africa: a systematic review. BMC Public Health 2018;18(1):1148. doi: 10.1186/s12889-018-6050-0. [Crossref]
30. Muchiri JW, Gericke GJ, Rheeder P. Stakeholders’ perceptions of dietary and related self-management challenges and education programme preferences for type 2 diabetes adults. Journal of Endocrinology, Metabolism and Diabetes of South Africa 2019;24(1):1-9. doi: 10.1080/16089677.2018.1541211. [Crossref]
31. Booth AO, Lowis C, Dean M, Hunter SJ, McKinley MC. Diet and physical activity in the self-management of type 2 diabetes: barriers and facilitators identified by patients and health professionals. Prim Health Care Res Dev 2013;14(3):293-306. doi: 10.1017/s1463423612000412. [Crossref]
32. Cooper HC, Booth K, Gill G. Patients’ perspectives on diabetes health care education. Health Educ Res 2003;18(2):191-206. doi: 10.1093/her/18.2.191. [Crossref]
33. Thomas JJ, Moring JC, Harvey T, Hobbs T, Lindt A. Risk of type 2 diabetes: health care provider perceptions of prevention adherence. Appl Nurs Res 2016;32:1-6. doi: 10.1016/j.apnr.2016.03.002. [Crossref]
34. Reyes J, Tripp-Reimer T, Parker E, Muller B, Laroche H. Factors influencing diabetes self-management among medically underserved patients with type II diabetes. Glob Qual Nurs Res 2017;4:2333393617713097. doi: 10.1177/2333393617713097. [Crossref]
35. Okrainec K, Booth GL, Hollands S, Bell CM. Impact of language barriers on complications and mortality among immigrants with diabetes: a population-based cohort study. Diabetes Care 2015;38(2):189-96. doi: 10.2337/dc14-0801. [Crossref]
36. Taber JM, Leyva B, Persoskie A. Why do people avoid medical care? A qualitative study using national data. J Gen Intern Med 2015;30(3):290-7. doi: 10.1007/s11606-014-3089-1. [Crossref]
37. Mikhael EM, Hassali MA, Hussain SA, Shawky N. Self-management knowledge and practice of type 2 diabetes mellitus patients in Baghdad, Iraq: a qualitative study. Diabetes Metab Syndr Obes 2019;12:1-17. doi: 10.2147/dmso.s183776. [Crossref]
38. Reynolds LM, Consedine NS, Pizarro DA, Bissett IP. Disgust and behavioral avoidance in colorectal cancer screening and treatment: a systematic review and research agenda. Cancer Nurs 2013;36(2):122-30. doi: 10.1097/NCC.0b013e31826a4b1b. [Crossref]
39. Lund C. Improving quality of mental health care in low-resource settings: lessons from PRIME. World Psychiatry 2018;17(1):47-8. doi: 10.1002/wps.20489. [Crossref]
40. Gask L, Macdonald W, Bower P. What is the relationship between diabetes and depression? a qualitative meta-synthesis of patient experience of co-morbidity. Chronic Illn 2011;7(3):239-52. doi: 10.1177/1742395311403636. [Crossref]
41. Concha JB, Kravitz HM, Chin MH, Kelley MA, Chavez N, Johnson TP. Review of type 2 diabetes management interventions for addressing emotional well-being in Latinos. Diabetes Educ 2009;35(6):941-58. doi: 10.1177/0145721709344125. [Crossref]
42. Halali F, Mahdavi R, Mobasseri M, Asghari Jafarabadi M, Karimi Avval S. Perceived barriers to recommended dietary adherence in patients with type 2 diabetes in Iran. Eat Behav 2016;21:205-10. doi: 10.1016/j.eatbeh.2016.03.001. [Crossref]
43. Heisler M, Piette JD, Spencer M, Kieffer E, Vijan S. The relationship between knowledge of recent HbA1c values and diabetes care understanding and self-management. Diabetes Care 2005;28(4):816-22. doi: 10.2337/diacare.28.4.816. [Crossref]
44. Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau MM. Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care 2002;25(7):1159-71. doi: 10.2337/diacare.25.7.1159. [Crossref]
45. O’Connor PJ, Crabtree BF, Abourizk NN. Longitudinal study of a diabetes education and care intervention: predictors of improved glycemic control. J Am Board Fam Pract 1992;5(4):381-7.
46. Buchmann M, Wermeling M, Lucius-Hoene G, Himmel W. Experiences of food abstinence in patients with type 2 diabetes: a qualitative study. BMJ Open 2016;6(1):e008907. doi: 10.1136/bmjopen-2015-008907. [Crossref]
47. Hill-Briggs F, Cooper DC, Loman K, Brancati FL, Cooper LA. A qualitative study of problem solving and diabetes control in type 2 diabetes self-management. Diabetes Educ 2003;29(6):1018-28. doi: 10.1177/014572170302900612. [Crossref]
48. Glasgow RE, Toobert DJ, Barrera M Jr, Strycker LA. Assessment of problem-solving: a key to successful diabetes self-management. J Behav Med 2004;27(5):477-90.
49. de-Graft Aikins A. Healer shopping in Africa: new evidence from rural-urban qualitative study of Ghanaian diabetes experiences. BMJ 2005;331(7519):737. doi: 10.1136/bmj.331.7519.737. [Crossref]
50. Utz SW, Steeves RH, Wenzel J, Hinton I, Jones RA, Andrews D, et al. “Working hard with it”: self-management of type 2 diabetes by rural African Americans. Fam Community Health 2006;29(3):195-205.