published_or_final_version / Social Work and Social Administration / Master / Master of Social Sciences

Self-monitoring of blood glucose (SMBG) can be effective in preventing poor outcomes associated with diabetes mellitus but previous research has identified that SMBG is not being undertaken in line with current recommendations. Guidance informs health professionals to educate patients on how they should self-monitor but very little is know about how patients self-monitor in the real world. In this thesis, a quantitative scoping study is first presented. This study used routine data sources to examine the levels and patterns of self-montoring in different population groups and then proceeded to a larger qualitative study to explore and question what patients are doing in practice in relation to self-monitoring, and why. This involved a qualitative multi-case study of patients, their support people, health care practitioners (HCPs) and patient diaries. Ten individuals and their nominated support people and HCPs formed ten cases among whom 21 in-depth semi-structured interviews were carried out and six patient diaries analysed. The exploratory work was framed around Stones’ version of structuration theory and uncovered a complex linkage of individual motives for monitoring, associated responses and behaviours in relation to the motive, and the underpinning attitudes and beliefs behind the motive. The following key points emerged from the analysis. People have differing relationships with their diabetes and this links with the level of engagement they have with their condition. Resistance to support people and health services was commonly observed. Experiences of diabetes reviews were important, with an identified need for them to feel more like collaboration and less like surveillance. A significant factor was the gaps and limitations in knowledge and understanding around diabetes for patients, relatives, support people and HCPs; and, finally, there was a noted maintenance of blood glucose levels higher than recommended through SMBG in several participants, which stemmed from a fear of hypoglycemic episode. The analysis concluded that although self-monitoring of blood glucose, in theory, and when considered in isolation, is a simple process to undertake, its application in the wider context of self-management and the individual is much more complicated. The process is influenced by many complex factors and generates a variety of responses and behaviours, some not in keeping with good diabetes self-management. There was a significant lack of person-centered approaches to managing diabetes which was, in part, due to existing health systems and processes. Therefore, there is a need to raise awareness of the gaps that exist in terms of such approaches as well as the gaps in knowledge and understanding of individuals with diabetes and those caring for and supporting them. In more specific terms, it is essential to develop and evaluate individual approaches to patients in relation to their self-monitoring and associated self-management in the context of their own lives, which involves the assessment of engagement and understanding around self-monitoring.

Introduction: Evidences indicate that human immuno-deficiency virus (HIV) and diabetes (DM) impact pregnancy outcomes but no experience on the integrated service delivery of HIV, DM and pregnancy care. This study explored the domains and levels of integration among DM, HIV and pregnancy care to prepare a service delivery model in Ethiopia. Methods: A sequential exploratory mixed method and the integration theoretical framework guided the study. An exploratory qualitative phase used focused group discussion, in-depth interview and observation to explore the level of integration and to refine a questionnaire for the quantitative phase. The data were transcribed and coded for theme-based analysis. The descriptive quantitative phase described HIV, DM and pregnancy care services, and determined the burden of DM among HIV patients and the prevalence of pregnancy and pregnancy outcomes. Data was analysed using Epi-info. The findings were triangulated, discussed and interpreted. Results: Seven themes were generated: joint plan, shared budget, monitoring system, structural location, the need of policy guide, the practice of integrated service delivery and suggested integration approaches. A coordinated HIV and pregnancy care services were noted. There was a linkage between diabetes and HIV, and diabetes and pregnancy care. The 1.5% of diabetes among HIV, the low number of pregnancies per a mother in diabetes (1.8) and HIV (1.3); the high adverse pregnancy outcomes among HIV (13.4% abortion, 12.4% low birth weight (LBW), 3.5% pre-term birth, 2.1% congenital malformation) and diabetes (3.2% big baby, 3.2% LBW, 3.1% Cesarean-section); the respective absent and low (16.2%) diabetes screening service at anti-natal and HIV clinics, the absent pregnancy care service for diabetic females justified the development of the tripartite integrated service delivery model of diabetes, HIV and pregnancy care. Conclusions: The model suggests active diabetes screening, evaluation and treatment at HIV and antenatal clinics. It considers the coordination between non-communicable diseases (NCD), HIV and maternal health units. Pregnancy care could be coordinated at HIV and NCD units. Full integration can be practiced between HIV and pregnancy care units. Preparing policy guide, building the capacity of health providers, advocating and piloting the model may be prioritized before the implementation of the model. / Health Studies / D. Litt. et Phil. (Health Studies)

Text in English / Interactive health communication between the health-care professional (HCP) and patient relationship for diabetes health-care positively contributes to patient-centred care. Hence individual patient concerns are addressed and catered for in the medical system. The purpose of this study was to analyse in-depth how HCP-patient relationships and HCP-HCP teamwork dynamics positively contribute to effective diabetes patient care and treatment adherence. Different health communication models and theories were reviewed and a conceptual framework was developed from the literature. A qualitative case study approach was used to collect data at Stanger Hospital’s diabetes clinic. Data was collected using three different methods, namely in-depth interviews with HCPs and patients individually, observations conducted at the clinic analysing both the HCPs and patients, and finally, documentation that emerged as a third data collection method where patient files and diabetes educational material were analysed at the clinic. Triangulation by means of the three methods ensured that reliable, valid and credible data was collected in the field. Diabetes health-care and treatment management are affected by the social context/social system which includes family and culture. These social factors are acknowledged as core in the literature. However, a single comprehensive health communication model did not exist solely in this regard. The data indicated that at the Stanger Hospital’s diabetes clinic, patient-centred (individual tailor-made treatment plans) care was only implemented after patients had defaulted treatment for reasons linked to their social circumstances. The findings of the study indicate that teamwork was favoured in the HCP-HCP relationship at the diabetes clinic, and that this made a positive contribution to effective diabetes patient care. HCPs were overburdened at the clinic since patient numbers were high and there were staff shortages. The patients’ empirical data indicated that interactive communication positively contributed to their medical concerns being catered for at the diabetes clinic, but this tended to occur only after non-adherence. Patients required care and support from HCPs in order to learn to accept diabetes and manage their illness. / Sociology / D. Litt. et Phil. (Sociology)