Background Diabetes mellitus is a chronic condition primarily characterised by elevated levels of plasma glucose due to a lack of insulin. Diabetes is a risk factor for a number of acute and chronic complications and is associated with significant morbidity and mortality, the risks and impact of which may be modifiable through high-quality primary care. This thesis examines the relationship between the quality of primary care and emergency admissions, readmissions and mortality. Methodology Associations between primary care quality and clinical outcomes for people with diabetes were assessed at the practice and patient level. Practice-level analyses, utilising Quality and Outcomes Framework (QOF) and Hospital Episodes Statistics (HES) data, modelled the impact of practice achievement of thematically-grouped QOF indicators on standardised emergency admission rates, controlling for characteristics of the practice, the socioeconomic environment and the patient population. Patient-level analyses utilised a Clinical Practice Research Datalink (CPRD-HES) dataset linking primary care activity with hospitalisations. Modelling examined associations between QOF target-based indicators and National Diabetes Audit (NDA) care processes and rates of emergency admissions, readmissions and the odds of death. Results In practice-level analyses, QOF indicators pertaining to processes of care and availability of appointments were most consistently associated with reduced emergency admission rates. For patient-level analyses, a number of NDA processes were consistently associated with reduced emergency admission and readmission rates and reduced odds of death across follow-up periods ranging from one to five years. Associations with QOF targets were less consistent. Across all practice- and patient-level analyses, deprivation was strongly associated with changes in admission rates and odds of death. Conclusions High-quality primary care has the potential to meaningfully improve outcomes for people with diabetes; the effects of socio-economic deprivation remain sizeable even after adjustment for primary care quality.

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Diabetes is a complex, chronic, insidious metabolic disorder. The marked prevalence in individuals with diabetes due to obesity, sedentary lifestyles and a poor diet, is proving a considerable challenge for healthcare systems across the world. In order to reduce diabetes related complications, it is imperative that individuals are able to effectively self-manage their condition. For this to be achieved it is crucial that the appropriate healthcare professionals provide on-going support and education. To date, this aspect has not been explored and we do not know what people with diabetes need in relation to support and education. Therefore, the aim of this study was to understand the experiences, perceptions and beliefs of what is important to a person with diabetes, in order to effectively self-care manage. A qualitative enquiry was undertaken, using a grounded theory approach to underpin sampling, data collection and analysis. Seventeen participants with type 2 diabetes were interviewed using a conversational style approach. Formal ethical approval was obtained from the NHS National Research Ethics Service and the University of Salford Research and Ethics Committee. All participants gave consent prior to data collection. Five principal concepts emerged from the data: i) Education, what education? ii) Why can’t they just tell you what diabetes is? iii) They just tell you what to do, they never ask about me iv) I just wanted a leaflet I could read and understand, they make you feel stupid v) I just carry on as normal The key theory to emerge illustrated that at the point of diagnosis limited significance was placed on the self-care management of type 2 diabetes. This study has revealed for the first time, that due to the apparent lack of significance the participants placed on type 2 diabetes, people do not sufficiently engage in appropriate self-care management. The participants did not necessarily view type 2 diabetes as a chronic condition due to experiencing little or no signs or symptoms, pre or post diagnosis. Despite the lack of full acceptance, participants passively recognised that ‘something needed to be done.’ Participants expressed a desire to be treated as a person with diabetes rather than the clinician’s focus on treating the disease in a generic manner. The theory suggests that there is a crucial and urgent need for timely, person focused, tailored information to be communicated effectively. Person centered care delivered in this way would maximise the effectiveness of self-care management in order to reduce the risk of serious consequences of diabetes. Further research opportunities could investigate the dialogue that takes place between healthcare professionals and individuals with type 2 diabetes. By establishing the individual’s comprehension of the information or education provided, this may afford a greater insight into patient understanding towards self-care management.

Diabetes is a condition often placed on the margins of ‘seriousness’. It is often believed to impact minimally on an individual’s everyday life and, while this may be true for some people, living with diabetes is not always experienced so ‘easily’. Research from myriad disciplines has begun to shed light on the complex personal issues of living with the condition, but, with a few exceptions, there is little input from human geography. This thesis hence explores the ‘geographies of diabetes’ in more detail. The findings hinge around a ‘recession’ of the diabetic body in public space. This recession is both discursive and material, caused by the assumptions and expectations of others that diabetes is among the minor of chronic conditions, largely overcome by insulin and ever advancing technologies which enable greater self-control over the diabetic body. Visible diabetic bodies are hence subject to a disciplining gaze, for having transgressed these expectations. This thesis finds that, despite many people displaying their diabetes minimally in public, the condition impacts greatly on a personal level. People with diabetes are aware that their bodies are at risk of both short- and long-term complications more so than if they did not have diabetes. These vulnerabilities serve to create anxious bodies for whom everyday spontaneity is curbed and dependency is heightened. In order to conceal the visible signifier of diabetes, to avoid the disciplining gaze, people ‘perform’ aspects of their self-management, hence further obscuring the anxious realities of living with diabetes. The embodied differences of having diabetes along with the discursive ‘recession’ of the condition, contribute to an ideal of ‘diabetic citizenship’. It is to this ‘diabetic citizen’ – who experiences the condition with few problems, and with any difficulty attributed to personal and moral failing – that many people with diabetes express their frustration. Through the methods of online questionnaires and face-to-face interviews, this thesis raises awareness of the clandestine geography experienced by people with diabetes.

Self-care, capability in performing certain activity in maintaining well-being in daily life, is regarded important especially among people with long-term condition such as diabetes. Locus of control and religion are regarded as important factors in influencing such particular activity in day to day basis. Indeed, among Javanese people the lingering culture cannot be separated from religion, influencing how they perceive any factors that might play into role in managing any ill-health condition. Utilizing a mixed methods study design, with the deployment of two screening tools for further semi-structured interviews (the Summary of Diabetes Self-care Activity and the Muslim Piety questionnaires), this study was aimed to explore further into the perceptions and experiences of Javanese Muslim with diabetes in utilizing religion with embedded cultural aspects, in managing their daily self-care activity. Subsequent to this, the study sought further into barriers and opportunities in performing self-care. A convenient sample of 100 participants has filled the questionnaires, and 24 participants from various gender and age groups were purposively collected to gain a richer perspective for further interviews. The study identified the moderate self-care practices as a separate notion, instead of an integrated and comprehensive concept. The study has also found that the act of surrendering or nerimo ing pandum among Javanese people, as a representation of external locus of control, is paramount in maintaining self-care. The state of surrendering has been shown in the belief in Allah as the determinative factor in managing self-care, and in how they were surrendering to the lacking of adequate access to healthcare services. Social support can be served as a hindrance in self-care, as well as supporting factor. The later notion has been shown in the role of Pengajian, a social religious activity, and Persadia, a peer support group, which have been performing more of a social hub in supporting not only in enhancing capability, but also psychological support. The role of external locus of control and the lack of healthcare access have been served as an opportunity in conducting an individualized approach in educating the Javanese Muslim in enhancing the capability and capacity in self-caring themselves, with collaborative work between the healthcare professional and the Muslim cleric.

This thesis explores the Ikojts' social representations and lived experiences of type 2 diabetes (henceforth diabetes) in Southern Mexico. Despite the prevalent urban impact of the diabetes epidemic, diabetes is increasingly affecting rural and, disproportionately, indigenous communities. This epidemiological profile has prompted the reading of diabetes in terms of an ethnoracial disease (Montoya 2011), with the consequence of downplaying the social, environmental and political-economic factors behind it. A central issue is how indigenous peoples themselves make sense of diabetes as the institutions of science and the state scrutinise and turn their focus to their bodies. Drawing on one year of fieldwork in the Ikojts community of San Dionisio del Mar, in Oaxaca, this thesis examines the multiple, sometimes contradictory ways in which the Ikojts live, narrate, make sense of and cope with diabetes. Adopting a critical phenomenologically inspired approach, this thesis focuses on the body as the prime site where experience is arrayed and where greater forces -- history, political economy, culture -- inscribe themselves. I argue that the Ikojts conceive diabetes as an idiom of and for vulnerability. In fact, diabetes is simultaneously the embodied manifestation of structural and ordinary violence and the bodily metaphor through which the Ikojts express emotional distress, compelling concerns, and duress, which characterise much of their daily lives. In this 'other' light, diabetes is not connected so much to genetics as it is to the experience of vulnerability. Through the exploration of a wide range of local experiences -- from domestic tensions, to witchcraft accusations, to breaks in moral order, changes in foodways, the fearful anticipation of disease, and the distrust in biomedical practitioners -- I analyse the manifold nature of vulnerability: its ontological character, subjective dimension, and structural organisation. Fully aware of the perils of superimposing categories such as 'vulnerable' or 'marginal' to human groups, this thesis presents an experience-near conceptualisation of vulnerability which sheds light on the complexities of living with diabetes in a hostile place and which goes beyond dominant understandings of diabetes as the result of populations' vulnerability to risky genetics or 'unhealthy' lifestyles.

Type 2 diabetes mellitus is a chronic disease that is associated with substantial morbidity, mortality, and health care cost. All patients with diabetes require a high level of clinical care to prevent the development of diabetic complications. The aim of this study was to compare the impact of a pharmaceutical care diabetic clinic within a primary care setting to standard care on clinical, humanistic and process outcomes in Type 2 diabetes patients. A randomised controlled trial was conducted in 9 general practices in Greater Glasgow Health Board. All patients with Type 2 diabetes, aged 18 years or over, taking an oral antidiabetic drug were recruited and stratified by practice, age, and gender, and then randomised into an active or control group. The patients in both groups were invited to a pharmaceutical care diabetic clinic within their general practice for three visits at three-monthly intervals. Active patients received review and allocated intervention by the pharmacist while control patients received review only without intervention by the pharmacist. Allocation remained blind until after the first evaluation. The pharmacist evaluated the appropriateness of the medication for the individual and their overall diabetic care. The pharmacist prepared a list of drug-related problems and a referral where appropriate. GP referrals were actioned in the active group but held back until after the conclusion of the study in the control group. Patient outcome measures include changes in HbA 1 c value, systolic blood pressure, health related quality of life (HRQOL), and drug related problems (DRPs) from baseline to the end of the study for both groups.

This thesis is concerned with exploring patients’ experiences of using a diabetes eHealth system. The context of the study is the growth of interest in eHealth systems that focus on patient needs, alongside increasing home computer use and the rising incidence of chronic diseases, such as diabetes. I aim in this thesis to make a novel contribution to knowledge about how eHealth technology is experienced by patients with diabetes. The study takes the form of a qualitative enquiry into the use of a diabetes eHealth system by a group of patients and their healthcare practitioners at a primary care general practice in Northern England. Using symbolic interactionism as a methodological perspective and taking elements from grounded theory the study produces a theoretical framework based on a thematic analysis of participants’ descriptions of their experiences of using the eHealth system. A diabetes eHealth system was designed and built for the study, and 38 patients were recruited from a single GP practice using purposive sampling. Participants used the system for six months and were interviewed at the beginning, middle and end of the study period. Issues of surveillance, automation, endorsement and interaction influenced use and experiences of the system. Results from the study indicate that participants use and perceive the eHealth system as part of their diabetes management experience. My thesis is that the eHealth system is a boundary structure through which boundary objects, such as electronically formatted blood glucose readings, are created and shared across different social worlds. The eHealth system crosses the boundary between two spheres of an individual’s diabetes management experience, the personal sphere of self-management, and the external sphere of seeking and receiving support from medical experts and others with diabetes. The co-location of these two spheres exposes participants to scrutiny but also opens up new possibilities for collaboration and learning.

Adherence to the health care advice is essential to prevent or minimize acute and long term conditions. Non-adherence to medical advice among people with diabetes is a common problem in every community. This study examined the diabetes knowledge (DKT), self-efficacy (CIDS) and other factors that enhance adherence to treatment and management of the condition in Libya. The study revealed that many Libyans with diabetes showed a low level of diabetes knowledge and did not generally adhere to their diabetes self-care regimen except for the medication regimen of taking tablets and/or insulin. The thesis concludes that various factors may explain poor adherence and the lower level of HbA1c level in this study. These include: self-efficacy about the management of the condition; duration of illness; type of treatment; cognitive factors; culture and social support; economic factors; stressful lifestyle; and health care services delivery. This study points to a need to improve health care services for diabetes, particularly health education, with more focus placed on socio-cultural and psychological aspects.

T2DM continues to be a public health burden with its increasing incidence, prevalence, and mortality risks. The aim of this thesis was to examine a population-based cohort of 22,000 people with T2DM diagnosed between 1 January 2000 and 31 December 2010 within the Wirral Peninsula, UK with the aim of: Assessing factors relating to all-cause, cardivascular-, malignancy-, and non-cardiovascular mortality; evaluating the role of glycaemic control, socioeconomic status, smoking, dyslipidaemia, blood pressure, obesity, and nephropathy, as predicting risk factors for mortality; assessing the influence of age at diagnosis, duration of diabetes, year of diagnosis and gender on mortality; examining the life expectancy and mortality patterns and measuring the years of life lost as a result of a diagnosis of T2DM; applying Complexity Science to the dynamic interplay of the various factors in T2DM that lead to unpredictability in health outcomes.