NURSING DEPARTMENT, MEDICINE AND HEALTH COLLEGE
Lishui University, China FACULTY OF HEALTH AND OCCUPATIONAL STUDIES
Department of Caring Sciences
The experience of self-care in persons with diabetes type 2.
A descriptive literature review
Cui Ying (Rebecca) Li Jinna (Anna)
2020
Student thesis, Bachelor degree, 15 credits Nursing
Degree Thesis in Nursing Supervisor: Zhao Lei (Charlie) Examiner: Annakarin Olsson, RN, PhD
Abstract
Background: Diabetes is a major global health problem and has become a pandemic worldwide. Among them, type 2 diabetes accounts for more than 90% of the total number of diseases. This is a chronic disease that requires self-care. People have encountered many obstacles and prerequisites in the process.
Aim: To describe the experience of self-care in persons with diabetes type 2.
Method: PubMed and Cinahl databases were used to search and select articles in the year period of 2009-2019 according to the PRISMA requirements. The subject-matter literature was adopted and analyzed.
Result: Through the study of the results of 10 qualitative articles, the experience of self-care in persons with type 2 diabetes were divided into two major themes: (1) prerequisite for persons with diabetes type 2. (2) obstacles for persons with diabetes type 2.
Conclusions: Persons with diabetes type 2 face a lot of prerequisites and obstacles when performing daily self-care. They need to strictly control their daily lives, learn related knowledge, receive help from the outside world, and maintain a positive attitude.
However, in this process, they often face great pressure and many challenges. Among them, nurses play an important role as they need to actively guide people to learn self- care and provide corresponding guidance.
Key words: Diabetes type 2; Persons experience; Self-care
Abstract
背景：糖尿病是一个主要的全球性健康问题，在世界范围内已成为大流行病。其 中 2 型糖尿病占疾病总数的 90％以上，这是一种需要自我护理的慢性疾病，人们 在这个过程中遇到了很多障碍和先决条件。
目的：描述2 型糖尿病患者在自我护理中的经验。
方法：使用PubMed 和 Cinahl 两个数据库，搜索选出 2009-2019 时间内的文献，
根据毕业论文准则与PRISMA 要求进行筛选文章。符合主题的文献均被采用和分
析。
结果：通过对10 篇定性文章的研究，将 2 型糖尿病患者的自我护理经历分为两个
主要主题：（1）2 型糖尿病患者的前提条件。（2）2 型糖尿病患者的障碍。
结论: 2 型糖尿病患者在进行日常自我护理时，会面临大量的先决条件和障碍。他
们需要去严格控制日常生活，学习相关知识和接受外界的帮助，并保持积极的心 态。然而，在这个过程中，他们往往会面临着很大压力和很多的挑战。其中，护 士扮演着重要的角色，他们需要积极引导人们学习自我保健并提供相应的指导。
关键词：2 型糖尿病;个人体验;自我护理。
Contents
1.Introduction... 1
1.1 Current situation... 1
1.2 Clinical manifestation...1
1.3 Self care, Self-management and Self-care management... 2
1.4 The nurse’s role... 2
1.5 Theoretical reference framework...3
1.6 Early review...3
1.7 Problem description...4
1.8 Aim and research question... 4
2.Method...4
2.1 Design...4
2.2 Search strategy...5
2.3 Selection criteria...6
2.4 Selection process and outcome of potential articles...7
2.5 Data analysis...8
2.6 Ethical considerations...8
3.Results... 8
3.1 Prerequisites of self-care in persons with type 2 diabetes... 9
3.1.1 Strict control of daily life...9
3.1.2 Support from many aspects... 112
3.1.3 Positive coping of psychological changes...14
3.2 Obstacles of self-care in persons with type 2 diabetes... 14
3.2.1 Major challenges of self-care... 14
3.2.2 Negative coping of psychological changes... 17
4.Discussion...18
4.1 Main result...18
4.2 Result discussion... 18
4.2.1 Prerequisites of self-care in persons with type 2 diabetes... 18
4.2.2 Obstacles of self-care in persons with type 2 diabetes... 18
4.3 Method discussion... 21
4.4 Clinical implications for nursing... 22
4.5 Suggestions for further research...23
4.6 Conclusions... 23
Reference...24
1.Introduction 1.1 Current situation
Diabetes is a chronic metabolic disease, which is characterized by hyperglycemia. The reason is that the body cannot effectively use the insulin it produces. Insulin production is not sufficient for human metabolism, or both (American Diabetes Association, 2014).
Diabetes is a major global health problem that has become more and more serious around the world and has reached a pandemic (Wynn, Howteerakul, Suwannapong &
Rajatanun, 2010; Hjlem, Mufunda, Nambozi & Kemp, 2003). According to the International Diabetes Federation, the prevalence of diabetes is expected to reach 334 million by 2025 (International Diabetes Federation, 2003). The annual global cost of diabetes care can reach hundreds of billions of dollars, which puts a heavy burden on the social and economic development of the world (Yong & Wu, 2017). Diabetes can be divided into two types: type 1 diabetes and type 2 diabetes: Type 1 diabetes is caused by a genetic defect in the body that cannot produce enough insulin on its own, a lack of insulin does not allow cells to store excess blood sugar (Yong & Wu, 2017). Type 2 diabetes is the acquired insulin resistance. The body's insulin secretion is normal, but the insulin receptor cannot work normally, resulting in the phenomenon of high blood sugar in the body (Yong ＆Wu, 2017). The American Diabetes Association describes type 2 diabetes as the most common type of diabetes, accounting for more than 90% of the total number of diseases (American Diabetes Association, 2007;Yong & Wu, 2017).
High incidence, mortality and the enormous burden of the interdisciplinary medical team make type 2 diabetes a major health issue (Al-Khawaldeh, Al-Hassan & Froelicher, 2012).
1.2 Clinical manifestation
Type 2 diabetes (T2DM) can occur at any age, and is more common in adults and the elderly over the age of 40 (Yong & Wu, 2017). Most of the onset is concealed and the symptoms are mild, but as the disease progresses, various acute and chronic complications may occur (Yong & Wu, 2017). Clinical manifestations mainly include polyuria, polydipsia, polyphagia and weight loss; itchy skin; limb pain, low back pain, menstrual disorders, constipation and so on, even lead to a series of complications, such as diabetic ketoacidosis, hyperosmolar hyperglycemia syndrome, diabetic foot, infection and hypoglycemia (Yong & Wu, 2017).
1.3 Self-care, Self-management and Self-care management
Self-care is defined as the care that incorporates any deliberate moves to look after physical, mental and emotional health, it is the act of caring for oneself when he is ill or to stop oneself from becoming ill (Bodenheimer, Wagner & Grumbach, 2002). Self- management is defined as “an active, responsible process of care, in which the patient works to maintain his or her health in close collaboration with the health care personnel”
(Tsourtos, Ward, Muller, Lawn, Winefield, Hersh, & Coveney, 2011). We can find that self-management is similar to self care, and self-care management is also the same.
Diabetes is a disease that can be controlled by self-care, which refers to maintain the optimal blood sugar of diabetes through healthy lifestyle behavior (Al-Khawaldeh et al., 2012; World Health Organization, 2016). Effective diabetes self-care practices have proven to be a good control which is a key of self-success and a good way to avoiding the complications (Tol, Shojaeezadeh & Eslami, 2012; Montague, Nichols & Dutta, 2005). However, the self-care of diabetes is challenging and depends to a large extent on the person's ability and willingness to perform complex and multifaceted treatments, requiring a combination of multiple therapeutic areas (Montague et al., 2005).
1.4 The nurse’s role
Improper daily self-care can exacerbate depression and emotional problems in person with diabetes type 2, and can even lead to a series of serious complications. Therefore, in order for diabetics to be able to conduct self-care activities, they need education, skills development, counseling and support (Ahmad, Zeina, Hafez, Jason, Rafat &
Ahmed, 2018). On the one hand, health care professionals such as diabetes specialist nurses are responsible for receiving training, learning cognitive and behavioral therapy, and strengthening their knowledge reserves and skills (Wallace, Seligman, Davis, Schillinger, Arnold, Bryant-Shilliday & DeWalt, 2019). On the other hand, nurses are responsible for brief training for persons, helping individuals to change their living habits, adopting a healthier lifestyle, guiding persons to focus on themselves, strengthening personal care and mental health, and promoting overall health of persons (Sato & Yamazaki, 2012; Wallace et al., 2019; Whittemore, Melkus, Sullivan & Grey, 2004).
1.5 Theoretical reference framework
Dorothea Orem´s nursing theory (Raile Alligood & Marriney Tomey, 2014) were used as a theoretical framework in present literature reviews. She describes that nurses should adopt three different care systems depending on the persons’ self-care needs and self-care ability (Raile Alligood & Marriney Tomey, 2014). Her three nursing systems are: the dependent care system is that persons’ daily activity is completely replaced by a nurse; the self-care deficit system is that some parts is replaced by nurses when the persons’ self-care ability cannot meet the self-care needs; the self care system is that the persons can take the necessary measures to complete self-care activities, but need nurses to provide support guidance (Raile Alligood & Marriney Tomey, 2014). In most cases, persons with diabetes still have physical, psychological, interpersonal and social functions, and can be able to learn self-care and take care of themselves under the guidance of a nurse. When a diabetic person has insufficient self-care ability or is completely unable to take care of himself, the nurse needs to perform partial or complete self-care activities on his behalf.
1.6 Earlier review
In the review study by Sohal, King-Shier & Khan, (2015), the result showed that there were obstacles for persons with T2DM to perform self-care: lack of knowledge, communication problems with health care providers and inconsistent communication, inability to abandon traditional dietary concepts, lack of specialized exercise facilities, preference for physiotherapy, and concern about the long-term safety of diabetes medications. In another review by Spencely & Wiliams, (2006), the result showed the prerequisites for self-care: appropriate use of culturally sports and dietary suggestions, increased self-care assistance and support from family members and social networks, and comparison with the self-care behavior of others. In the study of Li-Geng, Kilham
& McLeod, (2020), the influence of culture on East Asian Americans with T2DM self- care was emphasized, and the development of adaptive interventions to meet the needs of them: using bilingual education and culture-specific dietary recommendations to reduce the pressure of food adjustment and ensure reasonable dietary requirements.
1.7 Problem description
Type 2 diabetes is a health problem that threatens the world, and the number of person affected is increasing. Progress and complications of type 2 diabetes can be controlled and prevented by effective patient self-care (Ling, Vivien, Susan, Suan & Wenru, 2019).
Behavioral changes can effectively control blood sugar and control the progression of diabetes. However, it is a complex process that are influenced by many factors such as knowledge, beliefs, attitudes, and social support (Ling et al., 2019). At present, researchers focu on the treatment of type 2 diabetes, and have conducted a lot of researches on the experience and difficulties of medical staff caring for persons with type 2 diabetes. However, the field of experience research on self-care of persons with type 2 diabetes is still relatively blank, and there are few comprehensive reports on the experience of self-care of blood glucose control and maintenance of persons with type 2 diabetes. Therefore, comprehensive research in this field is urgently needed to ensure that they perform better self-care and improve the quality of life. Therefore, it is meaningful to discuss the experience of self-care in persons with type 2 diabetes. This research has important research significance. For nurses, clinical nurses can find from this article what kind of deficiencies in type 2 diabetes persons have in self-care, they can adjust various nursing interventions in a more targeted manner to support diabetic persons in self-care. For persons with type 2 diabetes, this research can provoke their reflection, they can improve their self-care behaviors, and they also have the opportunity to obtain guidance and help from doctors and nurses so that they have a positive attitude towards future life. For future research, this research can also fill the gap in this research field.
1.8 Aim and research questions
The aim of the literature review was to describe the experience of self- care in persons with diabetes type 2.
How do persons with diabetes type 2 experience self-care?
2.Method 2.1 Design
The study is a descriptive literature review (Polit & Beck, 2017).
2.2 Search strategy
Articles were found by searching in the databases PubMed and Cinahl, with certain limits: English language, published in the last ten years (2009-2019) and full text from the University of Gavle. The search terms that were used were diabetes type 2, self-care, persons experience and qualitative one by one and in different combinations with each other. When combining search terms, the Boolean term AND were used (Polit & Beck, 2017). Indexed search terms were fetched from Cinahl headings. In the preliminary search (see table 1) the titles and abstracts of 721 articles were skim-read, and 49 articles deemed to be of interest for the literature review were selected.
Table 1. Results of preliminary database searches.
Database +
Date of
search
Limits Search terms Number
of hits
Selected articles (excluding doubles) Medline via
Cinahl 2019-07-02
10 years, English full text from the University
of Gävle.
Diabetes type 2 47,456 0
Medline via Cinahl 2019-07-02
10 years, English full text from the University
of Gävle.
“Diabetes type 2” AND
“Self-care” 3206
6
Medline via Cinahl 2019-07-02
10 years, English full text from the University
of Gävle.
“Diabetes type 2” AND
“Self-care” AND
“qualitative”
438 18
Medline via Pubmed 2019-07-02
10 years, English full text from the University
of Gävle.
Diabetes type 2 79,510 0
Medline via Pubmed 2019-07-02
10 years, English full text from the University
of Gävle.
“Diabetes type 2” AND
“Self-care” 3860 5
Medline via Pumbed 2019-07-02
10 years, English full text from the University
of Gävle.
“Diabetes type 2” AND
“Self-care” AND
“qualitative”
283 20
Total：49
2.3 Selection criteria
To clarify the selection process and make the results of the database search easier to use, Polit & Beck (2017) suggested to use inclusion and exclusion criteria as shown below.
Inclusion criteria were used:
empirical research and articles from the persons’ perspective. Because the purpose of the study focused on the persons’ self-care experience, articles using qualitative methods and relevant to the purpose of the review study were used.
Exclusion criteria were used:
①Articles not related to the purpose of the current review, did not follow IMRAD (including introductions, methods, results, and discussions).
②The article which only focuses on the factors that affect the self-care of type 2 diabetes, and does not talk about the experience of person to self-care.
③Other review studies .
2.4 Selection process and outcome of potential articles
The title and abstract of this article were first reviewed to outline their role in answering research question in the literature review. After screening the article titles and abstracts, the authors read and carefully processed the results of the articles. First, they screened 22 articles and then examined them more closely to determine whether they were relevant to the literature review. Ten suitable articles were finally selected as the research objects. The authors carefully considered each step of the selection process.
(See Figure 1). The authors carefully analyzed the results of these 9 articles to identify similarities and differences in the experience of self-care for persons with type 2 diabetes, and then structured and classified them according to the appropriate themes.
2.5 Data analysis
Both the results sections and the processing sections of the selected articles were related to the research question. All articles were initially read separately by each author and then read several times together. To find common themes and patterns, the articles related to the aim were discussed, circled and color-coded for further analysis. To get an overview of the articles included, the authors used different tables, which made the analysis of the materials easier. Table 2 in Appendix 1 summarized the authors, titles, designs methods, study groups, data collection methods, and data analysis methods of the selected articles. After dividing the materials based on similarities and differences, authors finally identified two main themes and five subthemes. The results are shown in Figure 2. According to Polit & Beck (2017), this was a good strategy for finding themes, as well as a good opportunity to classify the collected materials in qualitative research.
2.6 Ethical considerations
All included articles were published papers and have been reviewed by a ethics committee, thus minimizing ethical risks. These articles have been read and reviewed objectively, independent of the author's own opinions and attitudes. The results have been displayed in their entirety and have not be changed as the author wishes. The written course was free of plagiarism. During the analysis and processing of the articles, discussions between the authors have been conducted several times, which helped to present objective results. This was a working method recommended by Polit & Beck (2017).
3.Results
The results were based on 9 articles using qualitative methods. This review described the self-care experience of persons with type 2 diabetes. Two major themes with five subthemes are shown in figure 2. The results were displayed in text form and as tables (Tables 2, 3 and 4). This review was based on research conducted in many different countries: Three articles are from Thailand, the remaining 6 articles are from Singapore, Ethiopia, Malawi, Portugal, Germany and Mexico. The age range of the sample is from 18 to 80 years old. Authors used five methods to collect data: individual and semi- structured interviews, field notes, audio and video recording, transcription, observations.
Authors used four methods to analyze data: content analysis, thematic analysis and iterative analysis method. The articles on which the results are based are marked with an
asterisk (*) in the reference list.
3.1 Prerequisites of self-care in persons with type 2 diabetes 3.1.1 Strict control of daily life
Most participants described that they had very high blood glucose levels due to their diabetes and that they must follow strict control over their daily lives, which was a major prerequisite for successful self-care (Lundberg & Thraku, 2012; Benavides- Vaello & Brown, 2016).
The vast majority of study participants believed that dietary control was one of the important prerequisites for self-care for people with diabetes type 2 (Tewahido &
Berhane, 2017). The participants described their usual eating habits, eating less rice, more vegetables and unsweetened fruits, eating different foods with friends, drinking water instead of sugar drinks, and eating less fried foods were all their strategies to control dietary intake (Lundberg & Thraku, 2011; Lundberg & Thraku, 2012; Tewahido
& Berhane, 2017; Li, Drury & Taylor, 2013; Benavides-Vaello & Brown, 2016).
Different countries had different dietary characteristics (Lundberg & Thraku, 2012).
Thais usually eat jasmine rice at every meal, if persons wanted to control diabetes, they should reduce the consumption of each meal (Lundberg & Thraku, 2012). Many people with diabetes said that tropical sweet fruits such as litchi, longan and durian usually contain high levels of natural sugars, which increased blood sugar levels (Lundberg &
Thraku, 2011). But there were almost no unsweetened fruits, they usually chose fruits recommended by doctors and nurses, such as guava and rose apples (Lundberg &
Thraku, 2012). Some people ate lemon and pig plums, and the fruit was as sour as lemon and gooseberry because they thought it would lower blood sugar levels (Lundberg & Thraku, 2018). They also believed that brewing cinnamon and plain water
and drinking it as tea would lower their blood sugar level (Lundberg & Thraku, 2018).
In Thai culture, people used herbs to maintain health and control diseases (Lundberg &
Thraku, 2018). Some women believed that herbs can help lower blood sugar, therefore, they used plant roots, leaves and stems to cook herbal drinks and drink water several times a day instead of water (Lundberg & Thraku, 2018). They mentioned gradoomthong, which was a kind of grass, they washed and dried, boiled with water, then removed the grass, they cooked with four to five Mayo leaves and a white head (Panda Palm), it just like tea, they can drink it every day (Lundberg & Thraku, 2018).
In Malawi, people with diabetes integrated what they have learned from the Malamuro Diabetes Program into their daily practice (Ogunrinu, Gamboa-Maldonado, Ndinda Ngewa, Saunders, Crounse & Misiri, 2017). One of the most common sense applications was to replace "Nsima" with "Ngaiwa", Nsima and Ngaiwa were commonly used starch staple foods (Ogunrinu et al., 2017).
"La Dieta" in Spanish stands for "food" in English, which was synonymous with healthy food and new technology (Benavides-Vaello & Brown, 2016). "La Dieta" had played a role in the subconsciousness of many participants as a method of treating diabetes, examples included reducing calories, increasing vegetables and fruit intake, limiting and carefully monitoring carbohydrate consumption, and reducing saturated fat by reducing bread and flour intake (Benavides-Vaello & Brown, 2016). Compared to fried foods, restricting the use of fats to make most meats and increasing sources of leptin, such as fish and chicken (Benavides-Vaello & Brown, 2016). The most common technique associated with "la Dieta" was por, which could control or limit the amount of food consumed (Benavides-Vaello & Brown, 2016). They also paid special attention to "use of forks", which referred to eating foods that required forks, not "finger foods", such as unhealthy tortillas or certain breads (Benavides-Vaello & Brown, 2016).
Most participants mentioned that exercise was good for controlling blood sugar level (Lundberg & Thraku, 2011; Lundberg & Thraku, 2012). Sports could include traditional sports such as walking, running or participating in other kinds of sports, as well as non- traditional sports such as agriculture or woodworking (Ogunrinu et al., 2017). Some women mentioned that they did aerobic exercise with other women two nights a week, and they believed that sweating can eliminate toxins or lower blood sugar level (Lundberg & Thraku, 2011).
Some women said they did housework, such as cleaning the room, as the way of exercising (Lundberg & Thraku, 2011).
Participants had a basic understanding of blood glucose-related knowledge, and they recognized that stable blood glucose level were one of the important prerequisites for self-management in place (Lundberg & Thraku, 2011). That's how they understood blood sugar and its relationship to food: every food contains sugar, which was taken into the body and stored somewhere, when there was too much in the body, drinking water like hungry, sugar would return to the blood (Lundberg & Thraku, 2012).
Most people agreed that it was important to see a doctor and check their blood sugar regularly (Lundberg & Thraku, 2011). They often chose to check in the community's primary health care unit or when they saw a doctor at a health center, and some people bought a blood glucose meter to test blood glucose at home (Lundberg & Thraku, 2011).
Most participants controlled their blood sugar levels by taking insulin (Lundberg &
Thraku, 2011; Tewahido & Berhane, 2017). Some participants said that if their sugar reading exceeded 250, they would adjust the dose and take more insulin, when it dropped, they lowered it to the previous dose (Tewahido & Berhane, 2017).
Religion had a subtle effect on people with diabetes, and many participants used prayer and religion as a coping strategy (Li et al., 2013). Muslim women in Thailand said they pray five times a day and believed in their religion as before, thinking it would help them recover from their illness (Lundberg & Thraku, 2011). They adjusted their medication time, such as taking doses before sunrise, and after sunset, they did not drink a lot of water or eat a lot of food (Lundberg & Thraku, 2011).
They believed that Buddhism could promote mental health and if they follow Buddhist principles, their lives would be better (Lundberg & Thraku, 2012). They tried to follow Buddhists' methods of abstaining from their diet, and they believed that rich food made it difficult to stick to their diet (Lundberg & Thraku, 2012). Aware of this difficulty, they did their best not to eat, because careful and moderate food intake was important to their health (Lundberg & Thraku, 2012).
Most participants considered their antidiabetic drugs a prerequisite for diabetes management and survival (Tewahido & Berhane, 2017; Bernhard, Ose, Baudendistel, Seidling, Stützle, Szecsenyi, Wensing & Mahler, 2017). They followed the drug instructions most and would adjust the dosage according to the doctor's instructions, because they knew that taking diabetes medications intermittently could put their lives at risk, such as accidental fainting and even death (Tewahido & Berhane, 2017). They knew that drugs made them stronger and they could continue their daily lives (Ogunrinu et al., 2017).
Most persons incorporate management drugs into their daily lives (Bernhard et al., 2017). For example, persons associate their medication time with a specific time (such as meal time) as a clue to medication (Bernhard et al., 2017). Persons also use tools such as pill boxes and easy-to-understand labels to help them manage themselves every day (Bernhard et al., 2017). Some persons also described their actions in response to disturbances in their daily lives, for example, they take preventive measures, such as planning foreseeable situations in advance, and adjusting their programs to respond appropriately to unexpected situations (Bernhard et al., 2017). In addition, a small number of patients indicated that they should carry the drug plan at any time, or scan all medical reports (including drug lists) on the USB flash drive, so as to notify the general practitioner in case of an emergency in case of emergency (Bernhard et al., 2017).
Most participants shared how to prevent complications from diabetes (Tewahido &
Berhane, 2017; Ogunrinu et al., 2017). Some Muslim participants monitored their blood glucose levels at home, but most were monitored at the primary health centre (Lundberg
& Thraku, 2018). Foot injuries and ulcers were complications that persons with type 2 diabetes would face, effective foot care was a prerequisite for self-care. Women paid more attention to foot hygiene than men, and paid more attention to choosing the right shoes (Tewahido & Berhane, 2017; Ogunrinu et al., 2017). They washed their feet, dried them, and often used nail clippers to cut their nails (Tewahido & Berhane, 2017;
Ogunrinu et al., 2017).
3.1.2 Support from many aspects
Most people with diabetes described how they learn to coexist with the disease, and outside help is an essential prerequisite (Lundberg & Thraku, 2011; Lundberg & Thraku, 2012; Ogunrinu et al., 2017).
Participants took a positive attitude to education and its importance, and treated healthcare providers who educate them positively (Ogunrinu et al., 2017). Most participants described that they would learn how to change lifestyles and controlled diseases through radio, books and pamphlets given to them by public health nurses (Lundberg & Thraku, 2011; Lundberg & Thraku, 2012), and they would also attend a diabetes education class provided by the hospital (Ogunrinu et al., 2017). They had also discussed their health issues with nurses in the primary care department and medical students visiting their homes (Lundberg & Thraku, 2011; Lundberg & Thraku, 2012).
Many people with diabetes tried to follow the doctor's recommendations, even if they found it difficult to do so (Lundberg & Thraku, 2011; Lundberg & Thraku, 2012).
For those who were not educated, they would receive counselling from a pharmacist or other health care provider during treatment (Ogunrinu et al., 2017).
They had received information about diet and had gained practical knowledge from the education programme, and they had shared their experiences (Lundberg & Thraku, 2018). Participants understood what should be included in the diabetes class (Ogunrinu et al., 2017). When asked what should be included in diabetes education, Participants said they were told what to eat and how to eat, the importance of exercise and the way of exercise (Ogunrinu et al., 2017). Blood sugar, drug related knowledge were also within the scope of educational knowledge (Ogunrinu et al., 2017).
One of the important prerequisites for diabetes and self-care was the support of family and social life (Lundberg & Thraku, 2011; Lundberg & Thraku, 2018; Lundberg &
Thraku, 2012). Participation facilitators generally included family, friends or acquaintances, health care professionals, the media, etc, they played a vital role in supporting and monitoring participants' self-care, their participation is part of the management plan (Laranjo, Neves, Costa, Ribeiro, Couto & Sá, 2015; Bernhard et al., 2017; Li et al., 2013; Benavides-Vaello & Brown, 2016).
Many participants noted that family was the driving force behind diabetes self-care (Lundberg & Thraku, 2011; Lundberg & Thraku, 2018). They received physical, mental, and financial support from family members such as partners, daughters, and sons
(Lundberg & Thraku, 2011; Lundberg & Thraku, 2012). These family members encouraged them to face diabetes, help them control the disease, and support them to reduce stress and anxiety (Lundberg & Thraku, 2011; Lundberg & Thraku, 2018).
Participants were also able to obtain experience-based knowledge about their condition, treatment and medical system guidance from family members diagnosed with diabetes (Laranjoet et al., 2015). The most common family support included preparing healthy food, reminding participants to take medication and insulin injections, meeting with a doctor and accompanying them (Lundberg & Thraku, 2011; Lundberg & Thraku, 2018;
Lundberg & Thraku, 2012).
Participants stated that they regularly consulted their peers to exchange information and experiences, and received useful specific help to manage diabetes (Laranjoet et al., 2015). Relatives and friends were important sources of information for some persons and provide assistance for daily medication management (Laranjoet et al., 2015). About
half of the participants reported that the Internet provides easy access to information related to diabetes self-care (Laranjoet et al., 2015).
3.1.3 Positive coping of psychological changes
Many people said they were really sad to have diabetes, but they must learn to accept it (Li et al., 2013). Most people with diabetes described how they learned to accept their illness, for these people, positive emotions mediated the effects of optimism and acceptance (Li et al., 2013). Some participants used prayer and religious beliefs as coping strategies, the first thing they did when they had anxiety was prayer (Li et al., 2013). Some persons were struggling to obey the fact that they had diabetes, they would discuss with their colleagues or doctors and participate in activities of the Diabetes Association (Tewahido & Berhane, 2017).
3.2 Obstacles of self-care in persons with type 2 diabetes 3.2.1 Major challenges of self-care
Almost all participants stated that following the advice of doctors and nurses to self-care was a hard job, and they often faced many obstacles (Lundberg & Thraku, 2011;
Lundberg & Thraku, 2012).
As most participants said, diet was the most problematic self-management behavior (Laranjoet et al., 2015). Participants noted that strict adherence to diabetes diet recommendations was almost impossible, and food restrictions exacerbated their cravings and made life more stressful (Tewahido & Berhane, 2017). Some young Thai women said dietary control was difficult because they were used to eating Muslim food (Lundberg & Thraku, 2011;Lundberg & Thraku, 2018). For people with diabetes in Malawi, the recommendation to switch from Nsima to Ngaiwa was a nutritional disorder, and participants often expressed their disgust with Ngaiwa and found it difficult to transition (Ogunrinu et al., 2017). Eating at large outdoor food centres was common in Singapore, but most foods sold in these centres contain large amounted of saturated fat and sodium (Li et al., 2013).
Obstacles to eating habits could be divided into four main categories: decision-making, food quality, food quantity and dietary arrangements (Laranjoet et al., 2015).
In decision-making, most participants mentioned the temptation to eat non-diabetic foods as a major challenge for diet control (Li et al., 2013). Many participants stated that they did not want to overemphasize their diet and simply avoided sugary foods and
beverages, but the desire for certain types of food (e.g., chocolate, desserts) made it difficult for some patients to avoid eating (Li et al., 2013).
In terms of quality, the cost of healthy foods and how to cook healthy recipes were common obstacles to improving diet quality (Laranjoet et al., 2015). Participants were usually able to correctly identify the general aspects of a healthy diet, but when choosing food and preparing meals, participants often had some misunderstandings (Laranjoet et al., 2015). A common misconception was that certain foods (such as potatoes, bananas, bread, cherry, Grapes, mung beans, beans) were considered
"disabled" for people with diabetes (Laranjoet et al., 2015).
In terms of quantity, participants stated that it was difficult to limit the number of servings per meal, and some mentioned that it was difficult to reduce their diet (Laranjoet et al., 2015).
In terms of time management, they must deal with the lack of free time because they must control their diet, take medication or insulin at the right time, and exercise (Lundberg & Thraku, 2011).
In addition, although most people with diabetes recognized that changing eating habits was critical to controlling diabetes, society's expectations had a large impact on their behavior (Tewahido & Berhane, 2017; Laranjoet et al., 2015). In social events such as weddings, sharing food was seen as a way of expressing respect and love for each other (Tewahido & Berhane, 2017; Laranjoet et al., 2015). Almost all participants thought that rejecting food provided by others would be regarded as offensive and insulting, so they would eat something they prepared, and social life was essential for them (Tewahido &
Berhane, 2017; Laranjoet et al., 2015).
Participants stated that they encountered many obstacles in their sports (Tewahido &
Berhane, 2017; Laranjoet et al., 2015). Many people admitted that they did not exercise regularly, the most common reasons were lack of interest, motivation and willpower, busy work schedules, living stress, unaffordable gym costs, and lack of exercise habits (Tewahido & Berhane, 2017; Laranjoet et al., 2015). Exercise was difficult for Thais because they depended on garlands for their livelihood., they must sit down from morning to night to make Roy Mari flowers until the jasmine wreath was complete (Lundberg & Thraku, 2011).
Participants lacked information and amounted of exercise appropriate for their particular type of physical exercise, as well as knowledge of how often they should exercise, and lacked guidance from a health care professional on an exercise program (Laranjoet et al.,
2015). Considering their limited physical activity, most participants considered poor physical condition to be a barrier to physical exercise (Li et al., 2013). They considered their body to be an obstacle to their physical exercise, for many participants were limited by heart problems and musculoskeletal pain (Laranjoet et al., 2015; Li et al., 2013). They lacked confidence in their performance limits and believed that too much exercise may hurt themselves, which made them uneasy about the proper level of physical exercise (Laranjoet et al., 2015; Li et al., 2013). They believed that there was a balance between improving physical health through exercise and avoiding overwork, as overwork may cause additional pain or problems (Laranjoet et al., 2015; Li et al., 2013).
Most participants said that although they realized that monitoring blood glucose levels was very important, they did not check their blood glucose levels regularly (Tewahido
& Berhane, 2017). Even persons with their own blood glucose meters at home had reported that their blood glucose was monitored every 4-6 weeks (Tewahido & Berhane, 2017). It was reported that those who did not have a blood glucose meter at home only go to a nearby private clinic or laboratory if they felt unwell (Tewahido & Berhane, 2017). These findings indicated that blood glucose monitoring was irregular and that there was a high risk of long-term diabetes complications due to poor glycemic control (Tewahido & Berhane, 2017).
Some participants reported that their experience with blood glucose self-monitoring was frustrating, and they felt that controlling blood glucose was beyond their ability (Laranjoet et al., 2015).
The most commonly mentioned obstacle to blood glucose control was stress (Laranjoet et al., 2015). Most participants felt that their anxiety about the disease made it difficult for them to achieve glycemic control (Laranjoet et al., 2015). In addition, persons were often confused and had a lack of understanding of sudden blood sugar rises (they cannot explain them based on diet), which made them often blamed for stress, the apparently unexplained lack of control often frustrated them and lacked motivation to adhere to recommended behaviors (Laranjoet et al., 2015).
Many participants also experienced obstacles to medication (Bernhard et al., 2017;
Tewahido & Berhane, 2017). These include persons' lack of knowledge and understanding of medication information, which were related to the persons’ personal circumstances, health status and resources (Bernhard et al., 2017). In addition, persons emphasized that they had difficulty assessing the quality of drug-related information, especially when they had access to the information online (Bernhard et al., 2017). Some
persons had indicated that self-management of medications was considered complicated if their treatment regimens interfere with their cultural / religious habits (e.g., Ramadan fasting prevents some patients from following their treatment regimens) (Bernhard et al., 2017). Most persons receiving insulin therapy mentioned an obstacle because of the lack of refrigeration equipment that they forgot to use insulin when traveling away from home (Tewahido & Berhane, 2017). Another common obstacle was pain and abscesses at the injection site caused by daily insulin injections, persons felt frustrated and scared when the pain became too severe, especially when there were obvious signs of swelling and abscesses at the injection site (Tewahido & Berhane, 2017).
Economy was one of the important factors hindering self-management (Bernhard et al., 2017). Some persons had limited financial resources and self-management of medications was an obstacle for them (Bernhard et al., 2017). When persons did not have the means to buy drugs again, they would choose to discontinue treatment (Ogunrinu et al., 2017). Most people with diabetes said they had to work to make money for their families, and they didn't have time to choose and prepare healthy food when they work, they were more concerned about making money for their families than controlling disease (Lundberg & Thraku, 2012).
3.2.2 Negative coping of psychological changes
Some people with diabetes faced anxiety and stress due to the disease itself, the complications caused by it, and the need to control blood sugar levels (Lundberg &
Thraku, 2012). They had a large psychological burden, although doctors and nurses told them how to treat and control the disease. However, many people didn't really know what to do (Lundberg & Thraku, 2012).
Participants had two main negative psychological changes to diabetes: "negligence" and
"confusion" (Tewahido & Berhane, 2017). The main manifestations of "negligence"
were: inaction, blaming God or destiny, mostly neglecting self-care behavior, refusing to discuss with colleagues or joining the Diabetes Association; the main manifestations of "confusion": anxiety / fear of complications, not knowing what is a complication.
Few self-care habits know about diabetes but are not involved (Tewahido & Berhane, 2017).
Physical symptoms associated with type 2 diabetes included frequent urination, sleepiness, and insomnia (Li et al., 2013). These symptoms, in turn, caused anxiety and helplessness as participants try to manage their illness (Li et al., 2013). The sense of
helplessness due to the unpredictability of blood glucose could cause participants to lose control of their lives, leading to loss of motivation and hope (Li et al., 2013). In addition, participants were concerned that if others knew they had diabetes, they would think differently. In fact, some participants did not tell friends that they had diabetes (Li et al., 2013).
4.Discussion 4.1 Main result
Our results showed that the experience of diabetes persons in self-care could be divided into two major themes: prerequisites and obstacles. The main prerequisites in the core elements of management were: healthy habits of diet, exercise and drug, interactions with each other, stable social support and a positive attitude. The main obstacles were:
unhealthy eating habits, irregular exercise, irregular blood glucose testing, poor medication habits, economic stress, and unstable moods.
4.2 Result discussion
4.2.1 Prerequisites of self-care in persons with type 2 diabetes
Many people with diabetes accepted the need to control their disease and tried to change their daily habits to control their blood sugar levels. As Orem said, person as an independent individual, had physical, psychological, interpersonal and social functions, and he had the ability to learn to take care of himself and take responsibility for the health of himself and his family (Raile Alligood & Marriney Tomey, 2014). Many articles mentioned that almost all participants said that they would try to avoid sugar and try to reduce their intake of sweet drinks and food (Benavides-Vaello & Brown, 2016; Lundberg & Thraku, 2011; Lundberg & Thraku, 2012; Li et al., 2013; Tewahido
& Berhane, 2017). This finding was in agreement with (Sohal et al., 2015) 's description of how diabetic persons controlled their daily diet: avoided high saturated fats, including lamb, beef, ghee, solid fats and spices; increased consumption of cooked rice and cereals, to improve their blood sugar control. In addition, Hushie (2019) mentioned that in addition to simple sugar and any sugary things (such as sodas and fruit drinks), people with diabetes should also eat high-fiber foods regularly. They could eat snacks, but did not add other foods that raise blood sugar levels. A structured meal plan and specific meal times were necessary.
Diabetes persons recognized anti-diabetic drugs as a prerequisite for diabetes management and survival, and would take medications according to doctors' instructions (Tewahido & Berhane, 2017). This echoed what Hushie, (2019) mentioned:
They would perform continuous and escalating medications. In addition, Hushie (2019) mentioned that people who did not believe in Western medicine therapy often took phytotherapy. This was similar to the special herbal remedies mentioned in the article (Lundberg & Thraku, 2011; Lundberg & Thraku, 2012): herbal drinks made by boiling the roots, leaves and stems of plants with water could help lower blood sugar.
Spenceley & Williams (2006) mentioned that persons' fear of complications of diabetes was also considered as a strong promoter of self-care, foot injuries and ulcers were complications that persons with diabetes often face in the middle and late stages, there was a possibility of amputation. In order to avoid this, they would pay attention to washing their feet, drying their feet, often cutting their nails with nail clippers, and choosing the right shoes to wear (Tewahido & Berhane, 2017; Ogunrinu et al., 2017).
The self-care of diabetic persons could not be separated from the support of family and social life. The article (Lundberg & Thraku, 2011; Lundberg & Thraku, 2012; Lundberg
& Thraku, 2018) mentioned that many participants believed that family was the driving force for self-care of diabetes. As mentioned in (Spenceley & Williams, 2006), self-care was closely related to support from family members and self-care assistance from spouse. This was consistent with Hushie study (2019): family members assisted in a variety of management strategies, such as adapting new eating habits to persons' eating habits and roles, and assisting in the preparation of recommended meals; When persons were "tempted" to ate "unhealthy" foods or ate late, checked them and reminded them to check their blood sugar levels.
Many participants recognized the importance of being actively involved in the education of health workers. Most participants trusted their health care providers, and Asian persons generally regarded doctors as an authoritative source of diabetes knowledge and management (Sohal et al., 2015). The media, especially television and newspapers, were regarded as a useful source of knowledge for women working at home (Rhodes, Nocon & Wright, 2003).
Orem theory emphasized the importance of nurses in self-care (Raile Alligood &
Marriney Tomey, 2014). Nurses were both educators and promoters, mainly responsible for persons with diabetes and their families, they needed to apply a wide range of nursing interventions to help people with diabetes self-care through knowledge and the
ability to improve self-care (Kumar, 2007). Through the popularization of diabetes diet, exercise, medication and other aspects of knowledge, strengthened the participants' awareness of self-care, so as to achieve the nursing needs of blood sugar control (Kumar, 2007).
Persons with diabetes had different psychological changes when coping with diabetes self-care. (Li et al., 2013; Tewahido & Berhane, 2017) noted, most people struggled to learn to accept it, many people used positive emotions to mediate optimism and acceptance, used prayer and religion as coping strategies. This was similar to what was mentioned in Moonaghi, Areshtanab, Jouybari, Bostanabad & McDonald, (2014):
participants who had positive beliefs about the disease and treatment believed that the disease could be controlled, cured, and eventually eradicated. There is also an article mentioned that exercise could stimulate positive emotions and reduce or buffer negative emotions (Moonaghi et al., 2014).
4.2.2 Obstacles of self-care in persons with type 2 diabetes
However, strict control of daily life was not easy, and they faced many obstacles.
(Lundberg & Thraku, 2011; Lundberg & Thraku, 2018; Li et al., 2013) mentioned that controlling diet was difficult and food restrictions exacerbated their cravings.
(Tewahido & Berhane, 2017 ; Laranjoet et al., 2015) mentioned that in social activities such as weddings, almost all participants thought that rejecting food provided by others would be considered offensive and insulting. This echoed what (Hushie, 2019; Sohal et al., 2015) mentioned: Because people provided too much temptation, it lead to a lack of healthier or more suitable food choices. In addition to the most common lack of interest, motivation and willpower (Tewahido & Berhane, 2017; Laranjoet et al., 2015), obstacles affecting physical activity included cold weather, the cost of exercise programs, fear of sports injuries, and transportation difficulties (Fagerli, Lien & Wandel, 2005).
Many participants acknowledged their lack of understanding of medication information to regulate medication. Hushie (2019) mentioned that when taking oral hypoglycemic drugs, some participants would reduce or miss the dose or worry about the side effects of the drug. And compared with oral hypoglycemic drugs, most participants considered insulin therapy to be the most troublesome and least feasible treatment (Moonaghi et al., 2014). Because of the lack of refrigeration equipment when traveling, persons who needed insulin treatment could not use insulin on time (Tewahido & Berhane, 2017).
Financial conditions could affect care for diabetes. Spenceley & Williams (2006) mentioned that financial constraints and living in poor, unsafe communities made it difficult for people to access diabetes care products. Moonaghi et al. (2014) also mentioned the difficulty of access to medical facilities and services caused by the low economic status.
(Hushie, 2019; Moonaghi et al., 2014) also argued that family members sometimes obstructed the participants' control of the disease, and family members did not understand the person's condition and were unable to empathize. some participants mentioned that family members were not able to adapt to the needs of people with diabetes.
The interaction between persons and care providers could also be a barrier. As Moonaghi et al. (2014) stated , the lack of common language between doctors and persons, and the lack of understanding of the person's situation by doctors, lead to the continuous problems in the life of persons. This could help people adapt to diabetes if doctors used plain language with persons and referred them to appropriate resources (Moonaghi et al., 2014). In addition, unstable and ambiguous health information released by the media was prone to confusion and conflict in understanding and co- existing with the disease (Moonaghi et al., 2014).
More people would face anxiety and stress when they were diagnosed with diabetes.
Spenceley & Williams (2006) mentioned that participants were fearful and worried about the uncertainty of the future of diabetes. They thought their illness was an incurable disease that would eventually lead to death (Moonaghi et al., 2014). In addition, according to Hushie (2019), they worried about being a burden to their families and not getting their support. To allay some of these fears, some persons preferred not to disclose their diabetes status to their families, pretended to be healthy as a way of managing the widespread fear of the disease (Hushie, 2019).
4.3 Method discussion
Polit & Beck (2017) believed that literature review was a good way to critically review and summarized previous research. This review could provide readers with a framework for obstacles and prerequisites of self-care in persons with type 2 diabetes.
According to Polit & Beck (2017), the authors of the study used clear and specific search strategy with certaion limitions to improve the accuracy of the study. However, these limitations could also cause restrictions. First, one of the limitations that authors
chose is that the article must be written in English, which may cause the authors to miss some good articles. Secondly, one of the limitations was that the article must be published between 2009 and 2019. This may cause authors to miss earlier studies, which was a limitation of the current literature review. However, it could also be seen as an enhancement as it ensures more timely and modern results (Polit & Beck, 2017).
According to Polit & Beck (2017), the authors worked in a systematic way and recorded every step of the research process to ensure an effective search. The authors chose a descriptive design as the aim of the study to describe the experience of self-care in persons with type 2 diabetes. Results were based on qualitative articles consistent with the objectives of this study. According to Polit & Beck (2017), this was a good choice.
The authors used two databases: PubMed and Cinahl to search for articles to ensure the credibility of the results. The authors also used Boolean term AND to get more target related articles. According to Polit & Beck (2017), this was an advantage because the results of this article would be smaller, more relevant to the goals and research questions, and the results would be more credible. MeSH may had more related articles, but not used in the article, which may lead to the omission of some important articles, which was a limitation.
Before writing the results, the two authors read the articles they chose separately to avoid affecting each other, and thought about the selected articles objectively and independently without any personal opinion. In the process, the two authors read the articles carefully to better understand their meaning.
Literature reviews indicated that type 2 diabetes is a global problem in different cultures.
None of these studies have been conducted in China, which was a limitation that may limit nurses' ability to transfer in clinical practice in the country.
4.4 Clinical implications for nursing
The number of person with type 2 diabetes continues to increase with economic and social development. Diabetes type 2 is a disease that can be controlled by self-care, which refers to maintain the optimal blood sugar of diabetes through healthy lifestyle behavior (Al-Khawaldeh et al., 2012; World Health Organization, 2016). However, the results of the study showed that persons with type 2 diabetes encounter obstacles in many aspects, such as unhealthy eating habits, economic stress, and unstable moods, which was due to the lack of appropriate support and knowledge guidance. When trying to explore and solve countermeasures, nurses should consider from multiple sides. From this article, clinical nurses can find the prerequisites and obstacles of type 2 diabetes
persons in self-care. In the future nursing process, they can increase the promotion of nursing support , adjust more targeted nursing interventions. The authors hope to meet the needs of persons with type 2 diabetes to control blood sugar , improve their quality of life, and use the study as data to support the development of self-care research for persons with type 2 diabetes.
4.5 Suggestions for further research
Through the research on the existing literature review data, we confirm that no research has been published in China that can well answer the research questions of this research.
In order to further improve the self-care ability of persons with type 2 diabetes, it is best to conduct a study in China from the individual perspective of the diabetic person. From this perspective, it is interesting to study the obstacles and prerequisites of self-care.
Early research has shown that people with type 2 diabetes have difficulty changing their ingrained lifestyles. If partners, nurses, doctors, and friends support them, their self-care skills will improve. This has certain guiding significance for further research in this field. Interestingly, the support of persons' religious beliefs to their disease adaptation in this study is an issue worthy of further research, because in China today, this is not a recommended strategy for coping with disease. Therefore, it is interesting to find evidence for this coping strategy.
4.6 Conclusions
Persons with diabetes type 2 face a lot of prerequisites and obstacles when performing daily self-care. They need to strictly control their daily lives, learn related knowledge, receive help from the outside world, and maintain a positive attitude. However, in this process, they often face great pressure and many challenges. Among them, nurses play an important role as they need to actively guide people to learn self-care and provide corresponding guidance.
Reference
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