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Self-management profiles and metabolic outcomes in type 2 diabetes

Full Text
Journal of Advanced Nursing
Self-management profiles and metabolic outcomes in type 2 diabetes
ISSN: 0309-2402
Accession: 00004471-200610010-00008
Author(s):

Vég, Anikó BSc; Rosenqvist, Urban MD PhD; Sarkadi, Anna MD PhD

Issue:
Volume 56(1), October 2006, p 44–54
Publication Type:
[Issues and innovations in nursing practice]
Publisher:
Copyright © 2006 Blackwell Publishing Ltd.
Institution(s):
PhD Student, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden (Vég)
Professor, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden (Rosenqvist)
Senior Lecturer, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden (Sarkadi)
Correspondence: Anikó Vég, Department of Public Health and Caring Sciences, Uppsala University, Uppsala Science Park, SE-751 85, Uppsala, Sweden. E-mail: aniko.veg@pubcare.uu.se
Accepted for publication 12 March 2006
Keywords: empirical research report, haemoglobin A1c, nursing, patient education, questionnaires, self-management, type 2 diabetes
Abstract

Aim: This paper reports a study whose aims were (1) to examine whether it is possible to determine participants' self-management profiles using three open-ended questions about their self-perceived role in diabetes management; and (2) to analyse whether such self-management profiles have any bearing on haemoglobin A1c levels.

Background: The behavioural and educational aspects of self-management in type 2 diabetes have been the topic of a number of investigations. The individual's role in maintaining health and a satisfying everyday life with chronic conditions is increasingly becoming the focus of secondary prevention.

Method: Participants (n = 259) were recruited from those attending a year-long health educational programme for people with type 2 diabetes at Swedish pharmacies. A questionnaire was distributed 24 months after baseline. The health outcome, haemoglobin A1c was measured on four occasions. Three open-ended questions were used to explore self-management profiles based on perceived role, goal, and need of support in treatment. Data were collected during the period 1997–2002.

Findings: The following profiles of participants emerged: Disease Manager, Compliant, and Disheartened, with no initial differences in metabolic control. However, during the programme Disease Managers achieved good glycaemic control and succeeded in maintaining the reduction in their blood glucose for a longer period than those in other categories: their haemoglobin A1c level was reduced by -0·35 at 6 months (P = 0·000), -0·30 at 12 months (P = 0·001), and -0·28 at 24 months (P = 0·001) after baseline. Compliant participants had a good everyday routine and a -0·18 reduction at 6 months (P = 0·028) but no statistically significant haemoglobin A1c level reduction later. A smaller group of people, the Disheartened, reported difficulties in living with diabetes and did not succeed in decreasing their haemoglobin A1c by statistically significant amounts.

Conclusion: Healthcare professionals could use our three open-ended questions to assist in understanding people's views of their role in disease management so that health promotion and education can be tailored to individual needs.



Introduction

Self-management profiles and metabolic outcomes in type 2 diabetes

An individual's role in maintaining health and a satisfying everyday life with chronic conditions is increasingly becoming the focus of secondary prevention. Today's educational approach is often more proactive and more focused on health promotion compared with earlier, compliance-based models of care (Funnell & Anderson 2003, Funnell 2004). The focus is now on enhancing effective self-management in people who live with chronic conditions rather than merely conveying information about a certain disease and expecting rigorous compliance with treatment schedules. The rationale for this is that people who take active control of their disease and have high self-efficacy are better able to cope with the challenges of living with a chronic condition. In several chronic conditions where interventions have been made to increase the self-efficacy of patients, it has been reported that patients experience lower levels of pain and disability and need to access healthcare services less frequently (Lorig et al. 2000). This model sees self-management as more than self-care and patient education in the traditional sense, and encompasses a concentration of knowledge and skills where the positive changes of self-efficacy make the improvement in health status possible (Lorig & Holman 2003).

The primary goal for healthcare personnel is to help patients find a way of taking control of their disease and achieving desired outcomes that are agreed in a between the person and the carer (Wagner et al. 1996). With this shift of paradigm, concepts such as health beliefs (Bradley 1995), stages of behavioural change (Prochaska & Velicer 1997), and self-management strategies have received considerable attention in the study of chronic diseases. Type 2 diabetes is no exception to this trend. In fact, the globally rising incidence rates of the disease, along with the implied burden for healthcare (King et al. 1998), have made behavioural and educational interventions aiming to improve self-management in type 2 diabetes the subject of a number of investigations (Ellis et al. 2004).

Background
Models of learning self-management in diabetes

Especially, helpful in understanding how individuals develop successful strategies for disease management are qualitative studies of patients' experiences. Price (1993) was the first to describe a step-by-step model on how persons with type 1 diabetes learn self-management. She divided the learning process into two main phases with some overlapping conditions in-between. The final stage in phase 1 occurs when a person has developed a basic routine and personal way of dealing with the disease through experience. Phase 2 describes a higher level of self-management where the individual is able to make changes to a well-functioning routine in order to adapt to new situations (Price 1993).

Ellison and Rayman (1998) described the process of learning diabetes self-management in three phases: ‘management as rules’, ‘management as work’, and ‘management as living’. The women interviewed in their study had type 2 diabetes and they did not seem to experience a stepwise development of self-management. Rather, they moved forward and backward between the phases: sometimes self-management worked satisfactorily, whereas sometimes these patients had a feeling of going back to an earlier stage (Ellison & Rayman 1998).

Yet another model of expert self-management in type 1 diabetes described four distinct phases on an evolutionary trajectory: passive compliance, naive experimentation, rebellion, and active control (Paterson & Thorne 2000). Although these phases were inter-related, there was no evidence of all persons necessarily going through each stage. However, all participants reported adopting a role of passive compliance at the beginning of the treatment. Whether or not, and how, the patients became experts in managing diabetes, as well as the time needed for this process, strongly depended on the individuals' personal resources and their social background.

Importance of self-perceived role in diabetes management

The developmental processes of self-management in diabetes described above stem from studies where participants reported retrospectively about their experiences. The question of how patients perceive their ability to manage their disease at any given time point, however, is left unanswered. We intended to capture patients' current perceptions in a previous study by asking them to describe their role in diabetes management using open-ended questions in a survey. Our findings underlined the importance of participants' self-perceived role in metabolic outcomes. Describing oneself as having an active role in diabetes treatment was highly influential in the regression equation predicting haemoglobin A1c (HbA1c) levels (Sarkadi et al. 2005), more so than biological and demographic variables.

The study
Aim

The aims of this study were (1) to examine whether it is possible to determine patients' self-management profiles using three open-ended questions about their self-perceived role in diabetes management; and (2) to analyse whether such self-management profiles have any bearing on HbA1c levels.

Participants

Participants were recruited from those a widespread study circle education programme at a number of pharmacies in Sweden for people with type 2 diabetes. Potential participants received leaflets and information about the programme, called study circles for diabetes. We had previously found that systematically educated pharmacists could perform group education for persons with type 2 diabetes (Sarkadi & Rosenqvist 1999). Therefore, each study circle group was led by a specially trained pharmacist, assisted by a diabetes specialist nurse, who helped with blood glucose monitoring skills during the initial phase. The groups met monthly for a year. The focus of the intervention was to teach participants diabetes management, such as self-monitoring, decreasing blood sugar levels through exercise, and choosing appropriate foods. All participants continued their routine care and the study circle was a complementary part of their diabetes treatment. The pharmacists were asked to emphasize repeatedly the importance of participants' experiences in the learning process. Therefore, participants' own log-books were frequently used as educational tools to analyse the effects of changes in diet, medications, or exercise. After conducting a randomized study, the concept of study circles for group education in diabetes was disseminated throughout Sweden (Sarkadi & Rosenqvist 2000). The randomized controlled trial report was published later, in 2004 (Sarkadi & Rosenqvist 2004).

Outcome measures

Measurement of capillary blood samples of HbA1c was the main outcome measure of metabolic success (Jeppsson et al. 2002). Samples were collected at baseline, after 6 months, at the last meeting, i.e. at 12 months, and on one occasion after the end of the programme, 2 years after baseline (identified below as t0, t6, t12 and t24, respectively). Haemoglobin A1c is a specific subtype of the haemoglobin present in human red blood cells. Depending on the sugar levels in an individual's blood, glucose binds to HbA1. It is the ‘sugared’, or glycated, haemoglobin – HbA1c– that is used to measure an individual's blood sugar levels during the previous 6–8 weeks (Tahara & Shima 1995). There is strong scientific evidence that levels of HbA1c are linearly correlated to later complications of diabetes (Reichard et al. 1993, The Diabetes Control and Complications Trial Research Group 1993, United Kingdom Prospective Diabetes Study Group 1998, Adler et al. 2002, Hippisley-Cox & Pringle 2004) and HbA1c is therefore considered a suitable target for and measure of treatment outcomes. The normal range of HbA1c is 3·5–5·3% in Sweden. Current national guidelines for diabetes treatment define an HbA1c of <6·5% linkindex="32" class="fulltext-RA" href="http://ovidsp.uk.ovid.com/spb/ovidweb.cgi#134">Swedish National Board of Health and Welfare 1999). In our study, the samples for HbA1c were analysed at an accredited laboratory in Falun, Sweden and then sent to Uppsala University. Test results were communicated to the pharmacist group leaders, who used them as educational tools during the following group session.

Questionnaire

A questionnaire was administered at the end of the programme (t12) and again 1 year later, i.e. 2 years after baseline (t24). The first questionnaire consisted primarily of background variables, whereas the second included standard instruments, gender-specific questions, and a number of open-ended questions about participants' perceptions of diabetes management. Standard instruments included the SF-36 (Sullivan et al. 1995), the Hospital Anxiety and Depression Scale (Zigmond & Snaith 1983), diabetes-specific measures of autonomy-conducive attitudes of healthcare providers (Williams et al. 1998), and partner social support (Eriksson & Rosenqvist 1993). Three open-ended questions, designed to capture participants' intuitive beliefs about their roles in diabetes treatment, were analysed qualitatively: ‘What is your role in your diabetes management?’, ‘What is your goal with your diabetes management?’, ‘What kind of support do you need for your diabetes management?’. Data were collected between 1997 and 2002.

Ethical considerations

The study was approved by the research ethics committee of Uppsala University. Potential participants received information about the study as described earlier, and gave informed consent to participate in the study.

Data analysis

We employed both qualitative and quantitative methods for data analysis. In this paper, we describe results from the total population of participants in all completed study circles. The analyses were based on responses from 259 participants, previously diagnosed with type 2 diabetes. All were Caucasian.

Qualitative content analysis of responses to the open-ended questions

The three open-ended questions about participants' roles in their diabetes management were analysed together as a short text for each observation. The questions were answered by 227 individuals (87%). Of the 227 individuals, 191 (84%; 73% of the total population) were included in the content analysis where the minimum requirement was an answer to the first question: ‘What is your role in your diabetes management?’, as these answers were believed to reflect most clearly the person's views on diabetes management.

During the content analysis (Graneheim & Lundman 2004), each participant was assigned a category by AV (first author) after thoroughly reading through each short text. After this, the other two members of the research team (UR and AS) independently investigated the resulting categories to see if there was agreement on the categorization of texts. In 38 cases, 20% of the responses, there was a disagreement on the categorizations. In all cases a consensus was finally reached.

Statistical analysis

Paired t-tests and ANOVA were used to compare the HbA1c values both within and between the categories resulting from the content analysis for each time point of measurement (t0, t6, t12 and t24). Chi-square tests were used to examine differences between Disease Managers, Compliant and Disheartened patients (as the categories were named), in terms of gender, educational background, medical treatment, civic and employment status. Means comparisons and ANOVA were chosen to investigate the differences in group members' age, BMI, and disease duration. To assess statistically significant differences between each of the resulting categories compared with each other, dummy variables were used. All statistical analyses were carried out using SPSS (version 11.5; SPSS Inc., Chicago, IL, USA).

Results
Diabetes management profiles

Three categories or self-management profiles were identified: Disease Manager (n = 105; 55%), Compliant (n = 59; 31%), and Disheartened (n = 19; 10%). Eight responses (4% of 191) were inadequate, and not suitable for any category e.g. stating ‘I do not understand the question’. The characteristics of the respondents for each group are shown in Tables 1 and 2.


Graphic
Table 1 Participant demographics

Graphic
Table 2 Age, disease duration, BMI, and HbA1c values according to self-management profiles

The most obvious differences between the categories were participants' views on their role in and support needs for diabetes management. Fewer differences were found in participants' descriptions of their treatment goals: most of them wanted to achieve and/or maintain a good blood sugar level and live as normally as possible. However, there was a difference in how these goals were described: as a means to avoid threatening complications or to achieve health and well-being.

Further information about the categories is given below, with examples of patient's responses in each category shown in Tables 3–5.


Graphic
Table 3 Disease Manager category: examples of answers to open-ended questions

Graphic
Table 4 Compliant category: examples of answers to open-ended questions

Graphic
Table 5 Disheartened category: examples of answers to open-ended questions
Disease Manager

This category applied to 105 individuals, 63% female and 37% male. The mean age was 63 years, average duration of diabetes was 4·4 years, statistically significantly shorter than disease duration for the Compliant category (P = 0·005), Table 2. Most of those treated with diet only belonged to the Disease Manager group (P = 0·030), which is quite expectedly explained by their shorter diabetes duration (r = 0·330; P = 0·000), Table 1. Mean BMI at the t24 measurement was 27·6, i.e. these participants weighed less than those in the other groups (P = 0·048).

Disease Managers believed that they had a primary responsibility for their disease and declared that they had an active role in diabetes management. They described saw health promotion as their treatment goal – to keep a good glycaemic balance and feel as good as possible. They either had limited and specific support needs or they were happy with the support they had, whether it came from health professionals or their personal social networks. These people seemed to have integrated diabetes in their daily routines and appeared to take responsibility for their own role in living well with diabetes. Quotations from the respondents can be seen in Table 3.

Compliant

Compliant participants could also be called ‘good patients’, trying to apply all recommendations and knowledge about diabetes treatment to themselves. Of the 59 compliant participants, 53% were women and 47% men with an average age of 64 years. The mean duration of the disease was 7·5 years, which is statistically significantly longer than the Disease Manager group (P = 0·005). The mean BMI was 28·8 and was not statistically significantly different from the other groups. There was an over-representation of the Compliant among those having elementary school education only, implying that the Compliant had lower levels of education than the other groups (Table 1).

Participants in the Compliant category described their role as simply complying with treatment schedules: following the doctor's/nurse's advice, taking drugs according to prescriptions, and being very aware of diet and exercise. Their primary task in self-management was to treat diabetes as a disease with focus on the disease-specific issues. Some of them explicitly stated that they had a patient's role in the treatment process. The Compliant described their treatment goals in terms of maintaining status quo or possibly improving a little. These people felt a strong need for regular visits to clinics or other caregivers. They also expressed their need for other sources of support, such as their family members or peer groups. Quotations from the respondents can be seen in Table 4.

Disheartened

Participants in the Disheartened category seemed to have negative experiences regarding the every day routine of living with diabetes and a strong desire to get support for problem-solving. They were deeply concerned with their disease and expressed a wish to gain control of diabetes so as to be able to ‘get on’ with their lives. The 19 members of this group (68% female and 32% male) had an average age of 58, making them the youngest of the three groups (P = 0·046). Their mean disease duration was 4·2 years, not statistically significantly different from the other groups. Mean BMI (31·8), however, was highest in this group (31·8) compared with the others (P = 0·004). Proportionately, the Disheartened had spent more years in college, implying a generally higher level of education compared with the other groups.

Instead of describing their role in diabetes management, the Disheartened tended to provide different reasons or explanations as to why their diabetes-related routines did not work as they should. The reasons for not succeeding with controlling their diabetes as they wished were often explained as someone, such as bad health services, or something else's fault. Overweight or other health or psychic problems were often cited as reasons:

‘I do have the full responsibility, but I mistreat myself because of psychic problems.’
‘I am so tired, just feel kind of worthless.’
‘I wish I had more strength.’

Several of the Disheartened also stated they had a ‘passive’ role in managing diabetes. The Disheartened described poor control over their diabetes and health in general and expressed more frustration with fluctuating blood glucose levels compared with the two previous categories: ‘I feel it's a real mess, far too high values!’ Several Disheartened participants also feared the consequences of diabetes and the main goal with self-care for this group was to avoid complications, such as eye and foot diseases. Further quotations from the respondents can be seen in Table 5.

In terms of support needs, several of the Disheartened expressed a marked dissatisfaction with their physicians and wished to change to more competent and understanding ones. Their support needs seemed to be comprehensive and concerned barriers such as being overweight, low levels of motivation, and a wish for better relationships with health professionals.

There was no statistical difference between the groups in term of gender and civic status. Smoking status was not included in the analyses given that very few individuals were smokers.

Self-management profiles and metabolic outcomes

There was no statistically significant difference in the initial HbA1c values between the groups (values are shown in Table 2, P = 0·785). However, statistically significant differences were found between the three self-management profiles, both in terms of HbA1c reduction over time and mean HbA1c levels at different time points (Figure 1).


Graphic
Figure 1 Self-management profiles and HbA1c (P-values indicate statistically significant reduction within groups compared to baseline).

After 6 months in the study circle, all three groups showed some improvement in their HbA1c; the decrease in levels was statistically significant for Disease Managers and the Compliant (P = 0·000 and P = 0·028, respectively), but not for the Disheartened. However, only the Disease Managers maintained a prolonged reduction with statistically significant differences in their HbA1c between t0 and t12 (P = 0·001), and t0 and t24 (P = 0·001).

Discussion

The most important message of this paper is that participants' self-reported view of diabetes management was statistically significantly correlated to glycaemic control, with Disease Managers having better metabolic outcomes than the Compliant, who, in turn, fared better than the Disheartened.

The basis of these conclusions is a qualitative content analysis of respondents' answers to open-ended questions. Credibility in the analysis was enhanced by using category validation by co-researchers. This was especially important in this study as texts were short and in 20% of cases there was initial disagreement among the research team. In addition, representative citations were chosen for each category to give the reader insight to the contents of each category. Dependability was enhanced by the fact that data collection was longitudinal using the same data collection format. Transferability was addressed by comparing our findings with longitudinal descriptions of illness trajectories and constructing a model for broader use. In addition, detailed descriptions of participants' background variables have been provided.

A previous study in which patients were categorized based on their glycaemic control and then investigated their life histories and self-management philosophies gave similar results (Savoca et al. 2004). The final five categories of the Savoca study were the Committed and the Tentative with good control; and the Hopeful, the Hassled, and the Overwhelmed with poor glycaemic control. It would thus seem that whether one investigates starting out from the person's perceived role in management or categorizes patients based on glycaemic control, the correlation between HbA1c and personal attitudes will prevail. The cause-and-effect relationship of this correlation, however, can not be established in either study due to their cross-sectional designs.

In addition to differences in attitudes between the groups, some statistical differences appeared in respondents' characteristics, namely in BMI, educational level, diabetes duration, age, and medical treatment. Disease Managers were less overweight, and were more often on diet treatment only compared with the other groups. This could be interpreted as the Disease Managers having a milder form of diabetes that is easier to manage.

Likewise, it could be argued that the Disheartened as a group have major weight problems standing in their way of reaching desired metabolic outcomes. In fact, people from the Disheartened group appeared to have a generally low mood, feelings of dissatisfaction, or lack of mental energy. The relationship between higher BMI and depression in adults with diabetes is already known (Sacco et al. 2005), which helps us to better understand the complicated inter-relationship between overweight, blood glucose control and self-perceived role in diabetes management.

Contrary to our expectations and previous evidence (Trento et al. 2004), it was the Disheartened group that had higher levels of education compared with the other groups. Instead of positively affecting their problem solving abilities, more time in school seemed to make these persons more needy, with higher expectations of both the health care system and themselves. Being aware of not doing well in spite of knowing better could be especially frustrating.

The Disheartened group was also the youngest, implying the possibility of still having multiple roles to manage, which could produce conflicting demands (Sarkadi & Rosenqvist 2002). This group expressed much more dissatisfaction with healthcare providers, especially with doctors, compared with other groups. A possible reason for this might be the differences in priority-setting during the decision-making process between patients and health professionals. A Danish study reported a tendency in people with worse self-management to see the disease as something quite distant from, rather than integral part of their lives, an attitude that might obstruct the negotiation of treatment options and empowerment (Zoffmann & Kirkevold 2005).

The Compliant had the longest disease duration and the least years of education. It is possible that for this group of persons with type 2 diabetes the best way to manage long-term was to adhere to medical advice as far as possible and thus achieve desired metabolic outcomes. Moreover, the main goal with treatment and self-care of diabetes is, indeed, to achieve and maintain as low levels of blood glucose as possible. Even though most of our participants were close to national target values (HbA1c <= 6·5%), (Swedish National Board of Health and Welfare 1999), the new European treatment goal is HbA1c <= 6·1% (De Backer et al. 2003), suggesting a stricter treatment target in the future. Notably, the Disease Managers could not only decrease their HbA1c, but also maintain these lower levels during the 2-year follow-up, placing them within the new target levels of HbA1c. Disease Managers developed better self-management capacity, whereas no such change was observed in the other two groups.

A comprehensive model of learning self-management

We summarize existing self-management models for diabetes in a single comprehensive model, illustrated in Figure 2. The model was guided by the research on developing self-management in diabetes and altered by our experience of patient education in type 2 diabetes.


Graphic
Figure 2 Comprehensive model of learning self-management in diabetes.

In contrast to some other studies, we emphasize that there is not necessarily a linear relationship between the stages of learning self-management in diabetes. Rather, there is the possibility of movement between, and repetition of, different stages. An individual may relapse to a previous level of self-management at any achieved level, including even an ‘expert’ patient, if something unexpected, such as an acute illness or stressful life-event, should occur. Contrary to these relapses being counterproductive, it seems that people gain a great deal of experience and learn more from relapsing compared with having no setbacks at all (Basler 1995). Thus, sometimes being in ‘rebellion’ or in a state of ‘transitory dependence’, as well as naively experimenting, are important building blocks on the road leading to expert diabetes management.

In addition to personal related specifically to the individual, there are a number of external factors that affect the developmental process of learning to deal with diabetes in everyday life. These include social network and its ability to provide educational, emotional, physical and professional support. Both internal and external factors are included in the model.

The purpose of this model is to compare other models based on longitudinal experiences of learning self-management in diabetes to the disease management profiles identified in this cross-sectional study. So, how do the profiles of self-management fit into the longitudinal model of learning self-management? Compliance was clearly identified in all studies we identified; it seems that the compliant person exists as a recognisable ‘link’ in the healthcare system. In contrast, the position of the Disease Manager is determined as a ‘final destination’, or the outcome of this developmental model of self-management. The Disheartened group, however, could correspond to different stages. An individual who is diagnosed as someone in need of support (i.e. Disheartened right now) could either be experiencing the stage of ‘rebellion’ (Paterson & Thorne 2000) or be in a transitory dependence role. In fact, any relapse to an earlier or transitory stage – although probably useful for the future – could imply ambivalent attitudes towards diabetes and its treatment. May be it is a necessary part of living with a chronic disease occasionally to opt for neglecting self-care and prioritizing other needs. In a Finnish investigation, 19% of respondents belonged to the group that currently neglected self-care and thus had poor glycaemic control (Toljamo & Hentinen 2001).

Study limitations

The fact that, at the start, all groups had good glycaemic control in terms of HbA1c, according to the national guidelines, implies that we were dealing with a selected diabetes population. Thus, those more motivated and interested in their diabetes treatment may be over-represented.

Implications for practice

The question posed by our findings is whether it is possible for healthcare professionals to know when and how to intervene so that vicious circles of lack of control and difficulties in self-management can be cut short, and active coping supported with measures based on individual needs. It seems evident from the model above that people with a chronic illness need different kinds of support at each level of their self-management evolution, implying different tasks for health professionals in their encounter with patients (Table 6). The Disease Managers need to be respected in their autonomy, while retaining all rights for support in further developing their skills and knowledge. The Compliant might, for example, have to be encouraged to dare leave a strict scheme and experiment a little in order to move ahead in the cycle of self-management development. The Disheartened, on the other hand, might need a hindrance analysis, and education and support to help them develop the skills to move out of a negative/relapse period more rapidly. Essentially, health professionals must find ways to empower this group to take responsibility for their own health.


Graphic
Table 6 Practical implications for treatment of patients with different needs in diabetes
Conclusion

This paper adds to the growing body of research which shows that knowledge is not enough to improve self-management and explores what other factors need to be considered in order to help patients improve their self-management abilities. Very little research was found where the participants' perceptions were related to glycaemic control. The particular contribution of this study, therefore, lies in the fact that it provides further clarification of patients' self-perceived role in diabetes management and how these perceptions, in turn, are linked to the main medical outcome variable in diabetes, HbA1c. Although our experiences are based on diabetes we believe that the findings presented in this paper could be applied to a variety of chronic illnesses as a further step towards a more interactive consultation style. We believe that health professionals' skills to empower patients can be enhanced if they have tools to understand the current motivations and barriers of the person in front of them.

Acknowledgement

The study was supported by The National Corporation of Swedish Pharmacies, the Research and Development Unit for the Elderly, Northwest Stockholm County Council (ÄNV), and Uppsala University.

Author contributions

AV, UR and AS were responsible for the study conception and design and drafting of the manuscript. AV performed the data collection and data analysis. AV and UR obtained funding and provided administrative support. UR and AS made critical revisions to the paper. UR and AS supervised the study.

What is already known about this topic
* Most patient education programmes for people with type 2 diabetes achieve short-term improvement of metabolic control, as measured by HbA1c.
* The importance of self-care in diabetes is well-established, but we still know little about factors that encourage individuals to take an active and responsible role in self-management.
* Stages of learning self-management in diabetes, described in qualitative studies, include passive compliance, experimenting to find an ‘own way’, and active disease control.
What this paper adds
* Using three simple questions, it is possible to make a ‘self-management diagnosis’ and relate it to patients' current stage of self-management on an evolutionary trajectory.
* The resulting self-management profiles of participants were strongly related to glycaemic control, with Disease Managers having better metabolic outcomes than the Compliant, who, in turn, fared better than the Disheartened.
* Our three open-ended questions may assist healthcare professionals in understanding people's views of their own roles in disease management, so that health promotion and education can be tailored to individual needs.
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Keywords: empirical research report; haemoglobin A1c; nursing; patient education; questionnaires; self-management; type 2 diabetes



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