Independent and supplementary prescribing are the two main forms of non-medical prescribing (NMP) that have been practised in the UK since 2006. Most available studies have qualitatively investigated the impact of NMP, especially in primary care. This may be due to the fact that prescriptions are issued mainly by general practitioners in primary care. This PhD thesis aimed at investigating the clinical effectiveness of independent pharmacist and diabetes specialist nurse (DSN) prescribers in the management of patients with type 2 diabetes at outpatient clinics in hospitals. A literature review was firstly conducted to explore the current research on NMP around the world and the UK. A systematic review of the previously published randomised control trials (RCT) and non-RCT studies that focused on prescribing interventions of nurses and pharmacist was also conducted to explore the impact of their prescribing interventions in treating type 2 diabetes using HbA1c level as the primary outcome. A programme of work of three retrospective comparative database analytical studies was then carried out to investigate the impact of independent NMPs in type 2 diabetes care. This programme of work used electronic medical records of patients attending outpatient clinics of diabetes centres in two teaching hospitals in Manchester; one employed an independent pharmacist and the other employed DSN prescribers. A group of subjects seen by an NMP in place of a doctor during the study period were the study group and the control group were those who seen only by doctors. The primary outcome was the average yearly change of HbA1c amongst the two groups. Secondary outcomes were yearly change of total cholesterol, blood pressure and serum creatinine as well as body mass index. Five statistical models, which included multivariable regression, propensity score matching and sensitivity analyses, were utilised to control for confounding effects, and the nature of selection bias in the retrospectively comparative effectiveness research using secondary database resources. A total of 330 patients seen by a team including a pharmacist versus 975 by doctors only between January 2006 and January 2013 at one site; and 656 by a team including DSNs versus 3,746 patients seen by doctors only between January 2007 to December 2013 at the other. The studies found both prescribing pharmacists and DSNs are capable of achieving at least non-inferior improvements in diabetes outcome compared to doctors. The pharmacist achieved a mean 0.01% reduction in HbA1c level versus doctors who achieved slight increase (p<0.4). DSNs also achieved a mean 0.07% reduction compared to doctors. However, after adjustment with multivariate and propensity score as well as with propensity score matching, there were no significant differences between the two groups. These findings were consistent with the findings in the systemic review. Although an RCT is the only method that by definition would produce unbiased treatment effects, the use of propensity score methods here, have reduced the potential for bias that may remain unaccounted for in multivariate models without propensity scores. Adjusting for propensity scores using two different methods also gives more confidence that the results are as unbiased as possible. Nonetheless, caution in generalising the results is necessary because of the retrospective nature of the studies and deficiencies in the database used.

Objetivo Avaliar, em indivíduos com diabetes (DM), a resposta de glicose e triglicerídeos duas horas após a ingestão de uma carga alimentar (CA) e sua associação com características clínicas e a presença de doenças crônicas. Metodologia Foram incluídos 915 indivíduos com DM, participantes da linha de base do estudo ELSA-Brasil. Coleta de sangue foi realizada em jejum e duas horas após o consumo da CA, contendo 455 kcal; 14 g de gordura saturada e 47 g de carboidratos. Regressão linear foi utilizada para investigar preditores dos níveis de excursão (diferença entre níveis pós-carga e de jejum) de glicemia e trigliceridemia (variáveis dependentes). Regressão logística foi realizada para descrever a associação da excursão de glicemia e trigliceridemia (variáveis independentes) e a presença de complicações do DM (doença coronariana, infarto, angina, acidente vascular cerebral, ou insuficiência cardíaca). Resultados A mediana da glicemia de jejum foi de 150 (123–198) mg/dL e da excursão de glicose foi 45 (16–79) mg/dL, enquanto que a trigliceridemia de jejum foi de 140 (103–199) mg/dL e a excursão de triglicerídeos foi de 26 (11–45) mg/dL. Maiores excursões de glicemia foram associadas com duração do DM (incremento de 5,7 mg/dL, IC95% 3,7–7,6, a cada 5 anos de doença), uso de insulina (58,5 mg/dL, IC95% 45,43–71,55), outro medicamento para DM (13,6 mg/dL, IC95% 2,5–24,8), idade (4,1 mg/dL, IC95% 0,43–7,69, a cada 10 anos), nível de glicose basal (5,2 mg/dL, IC95% 1,0–4,1, a cada 25 mg/dL); o índice de massa corporal associou-se a menor excursão (-6,8 mg/dL, IC95% -9,7 a -3,85, a cada 5 kg/m²). Maior excursão de trigliceridemia esteve associada com glicemia em jejum (2,5 mg/dL, IC95% 1,64–3,38, a cada 25 mg/dL), e menor excursão associada com triglicerídeos de jejum (-2,97 mg/dL, IC95% -3,24 – -2,69, a cada 25 mg/dL). Conclusão A resposta pós-prandial esteve associada ao tempo de doença, à necessidade de insulina ou outro medicamento para DM, ao índice de massa corporal, além da idade e níveis basais de glicose e triglicerídeos. As excursões de glicose e triglicerídeos estiveram associadas a presença de comorbidades potencialmente tidas como complicações do DM. / Objective We aimed to assess, in individuals with diabetes (DM), the excursions of glucose and triglyceride levels two hours after consumption of a food load (FL) and their association with clinical characteristics and the presence of chronic diseases. Design and Methods We included 915 subjects with DM, participants of in the ELSA-Brazil cohort. Blood sampling was performed at fasting and two hours after consumption of a 455 kcal, 14 g saturated fat and 47 g carbohydrate FL. Linear regression was used to investigate predictors of levels of excursion (difference between post-load and fasting levels) of glucose and triglycerides (dependent variables). Logistic regression was performed to describe the association of glucose excursion and triglycerides excursion (independent variables) and the presence of DM complications (coronary heart disease, myocardial infarction, angina pectoris, stroke, or heart failure). Results The median fasting glucose was 150 (123-198) mg/dL and glucose excursion was 45 (16-79) mg/dL, whereas fasting triglycerides was 140 (103-199) mg/dL and triglycerides excursion was 26 (11-45) mg/dL. Increase of glucose excursion were associated with DM duration (increase of 5.7 mg/dL, 95% CI 3.7 to 7.6, each 5 years of disease), insulin use (58.5 mg/dL, 95% CI 45.43 to 71.55), use of another drug for DM (13.6 mg/dL , 95% CI 2.5 to 24.8), age (4.1 mg/dL, 95% CI 0.43 to 7.69, each 10 years), fasting glucose (5.2 mg/dL, 95% CI 1.0 to 4.1, each 25 mg/dL) and body mass index (-6.8 mg/dL, 95% CI -9.7 to -3.85, each 5 kg/m²). The triglycerides excursion was associated with fasting glucose (2.5 mg/dL, 95% CI 1.64 to 3.38, each 25 mg/dL) and fasting triglycerides (-2.97 mg/dL, 95% CI -3.24 to -2.69, each 25 mg/dL). In logistic regression models adjusting for gender, age, fasting glucose, duration of diabetes, use of insulin and/or other drug for DM, the excursion of glucose was marginally associated with the presence of any complication of diabetes and coronary heart disease. Conclusion Greater glycemic postprandial response was positively associated with indicators of less pancreatic reserve and negatively associated with obesity, while and the size of the response in triglycerides presented only minimal associations. Associations of excursion size with diabetes complications were present.

Study Hypothesis: People with diabetes when submitted to gingival treatment may have different perceptions and have an impact on their quality of life. Objectives: This study evaluated the effect of gingival treatment on quality of life related to oral health in type-2 diabetic patients (DM2). Methods: 150 patients were included in this study, 100 with gingivitis divided into two groups: diabetes (n=50) and control group (systemically healthy, n=50) in addition to a negative control group (systemically healthy and gingival health, n=50). The groups received professional treatment and oral hygiene instruction. Then the subjects were randomly divided into essential oils (Listerine total care, n=25) or placebo (n=25), six randomized groups total. To assess the impact of the Quality of Life Factor - QoL (OHQoL-UK questionnaire) and its interaction with DM (diabetic or non-diabetic), with treatment (essential oils or placebo) and with time bases (baseline and three months) in clinical factors (plaque and gingival indexes - PI, GI and probing depth - PD), microbiological factors (Porphyromonas gingivalis - Pg, Aggregatibacter actinomycetemcomitans - Aa, Tannerella forsythia - Tf and total bacterial load - TBL), immunological (interleukin 1&#946;-IL-1&#946;) and breath levels (volatile sulfur compound levels - VSC), we used multiple linear regression analysis. Comparative analyzes were performed intra-group (initial vs. final) and inter-group (in each experimental time) using the Bio Estat 5.0 and SPSS 14.0 software. Results: The value obtained in Cronbachs alpha test (0.971), the significance of the Bartletts test (p&#706;0,0001) and the value of 0.935 for KMO test indicated good agreement, correlation variables and adaptation of the size of the instruments sample that OHQoL was shown to be latent when subjected to factor analysis. The Multiple Linear Regression Analysis detected impact between QoL and treatment in GI (p=0.03) between the QoL and TBL (p=0.03) and between QoL and treatment in VSC (p=0.011). Conclusion: Participants with diabetes and gum disease who reported improvement in quality of life tend to have better periodontal health and breath indicators, especially when a daily rinse with essential oils mouthrinse is executed. / Hipótese do estudo: Indivíduos com diabetes quando submetidos ao tratamento gengival podem apresentar diferentes percepções e gerar impacto sobre sua qualidade de vida. Objetivos: Este estudo avaliou o efeito do tratamento gengival sobre a qualidade de vida relacionada à saúde bucal de indivíduos diabéticos (DM). Metodologia: Foram incluídos no presente estudo 150 indivíduos, sendo cem com gengivite divididos em dois grupos: diabetes (n=50) e Controle (sistemicamente saudável, n=50) em adição a um grupo controle negativo (sistemicamente saudável e com saúde gengival, n=50). Os grupos receberam profilaxia profissional e instrução de higiene bucal. Em seguida os indivíduos foram aleatoriamente distribuídos em óleos essenciais OE (Listerine cuidado total, n=25) ou placebo (n=25), totalizando seis grupos aleatorizados. Para avaliar o impacto do Fator de Qualidade de Vida - FQV (questionário OHQoL-UK), bem como sua interação com DM (diabético ou não diabético), com tratamento (óleos essenciais ou placebo) e com o tempo (baseline e três meses), nos fatores clínicos (índices de placa e gengival IP, IG e profundidade de sondagem PS), microbiológicos (Porphyromonas gingivalis - Pg, Aggregatibacter actinomycetemcomitans - Aa, Tannerella forsythia - Tf e carga bacteriana total - CBT), imunológicos (interleucina 1&#946; IL-1&#946;) e halitométricos (níveis de compostos sulforados voláteis CSV), foram utilizados modelos de Regressão Linear Múltipla. Análises comparativas foram realizadas intra-grupo (inicial vs. final) e inter-grupos (em cada tempo experimental) com auxílio do software Bio Estat 5.0 e SPSS 14.0. Resultados: O valor obtido em Alpha de Cronbach (0,971), a significância do teste de Bartlett (p&#706;0,0001) e o valor de 0,935 para o teste KMO indicaram boa consistência, correlação de variáveis e adequação do tamanho da amostra do instrumento OHQoL que foi demonstrado estar latente quando submetido a uma análise fatorial. O Modelo de Regressão Linear Múltipla detectou impacto entre o FQV e o tratamento em IG (p=0,03), entre o FQV e CBT (p=0,03) e entre FQV e tratamento com OE em CSV (p=0,011). Conclusão: Participantes com diabetes e gengivite que relataram melhora na qualidade de vida tendem a apresentar melhores indicadores de saúde periodontal e hálito, principalmente quando fizeram uso diário de solução à base de óleos essenciais.

Le tissu adipeux brun (TABr) est devenu ces dix dernières années le centre d’intérêt de nombreux laboratoires en raison de sa capacité à dissiper l’énergie apportée par les substrats sous forme de chaleur. Chez les mammifères, le développement du TABr intervient à la fin de la gestation et devient fonctionnel à la naissance. Sa capacité thermogénique permet aux nouveau-nés de s’adapter face à l'environnement extra-utérin, puis son activité régresse avec l’âge. Ceci suggère que l’environnement intra-utérin joue un rôle important dans la programmation de la physiologie et du métabolisme du TABr. Dans un modèle bien décrit de retard de croissance intra-utérin, qu’est la carence protéique maternelle (CP), la jeune progéniture CP est normoglycémique malgré un défaut de sécrétion de l'insuline mais développe avec l'âge une résistance à l'insuline et une hyperglycémie. Lors de mon arrivée au laboratoire, des résultats suggéraient un rôle du TABr dans les changements dynamiques du profil métabolique de la progéniture CP en fonction de l'âge. En effet, le TABr des rats CP est hyperactif à 3 mois par rapport aux animaux contrôles alors qu’il revient au niveau des contrôles chez la progéniture CP âgée de 18 mois, ce qui corrèle avec l’apparition des troubles métaboliques caractéristiques du diabète de type 2. Durant ma thèse, mon premier objectif a été de démontrer le rôle causal du TABr dans le maintien de l’homéostasie glucidique chez les jeunes animaux CP. Pour ce faire, nous avons exposé au froid de jeunes rats CP pour solliciter leur TABr et nous avons procédé à l’ablation chirurgicale de ce tissu. Nos résultats montrent que la jeune progéniture CP est mieux protégée que les contrôles à une exposition au froid grâce à l’activité thermogénique accrue de leur TABr. / Brown adipose tissue (BAT) has grown over the last ten years into the center of interest for many laboratories due to its capacity to burn energy derived from metabolic substrates into heat. Indeed, in mammals, the development of BAT occurs at the end of gestation to become fully functional at birth. Its thermogenic capacity allows newborns to face extrauterine environment, and thereafter its activity declines with age. This suggests that the intrauterine environment plays an important role in the programming of BAT physiology and metabolism. In a well-known model of intrauterine growth retardation (IUGR), the maternal protein restriction model (called LP for low protein), the young LP progeny is normoglycemic despite an insulin secretion defect but develops insulin resistance and hyperglycemia with age. When I started my thesis work, available results in the laboratory suggested a role of BAT in the dynamic changes of the LP progeny metabolic profile according to the age. Indeed, BAT of young LP rats is hyperactive at 3 months compared to controls while this activity drops back to control levels in old 18-months LP progeny, consistent with the appearance of a type 2 diabetic phenotype. During my thesis, the first objective was to search for the causal role of BAT in the maintenance of glucose homeostasis in young LP progeny. Using a first strategy, we exposed young LP progeny to a cold challenge to activate their BAT. In a second approach, we performed surgical ablation of their BAT. Our results show that young LP progeny is more protected against a cold challenge than controls, due to the high thermogenic capacity of their BAT. However, BAT ablation induces hyperglycemia in young LP animals showing that this tissue is required to maintain their normoglycemia. This work, published in Diabetes in March 2017, suggests that a deleterious fetal environment could reprogram BAT metabolism. The second objective of my thesis was to identify the molecular mechanisms allowing the maintenance of active BAT in young LP progeny. To do so, we compared two models of BAT activation, ie our LP model and a well-known model of BAT activation with an agonist of β-3 adrenergic receptors. In both cases, when BAT is active, we observed a global increase in microRNA (miRNA) expression associated to augmented miRNA machinery expression, and in particular AGO2 expression. Interestingly, when BAT is inactive in old LP animals, miRNA expression and miRNA machinery expression return to control levels. While activation of mature brown adipocytes in vitro leads to an increase in AGO2 protein expression, partial deletion of this protein is sufficient to decrease the thermogenic activity of these cells. Collectively our data suggest that AGO2 and increased miRNA expression contribute to BAT activation. The manuscript concerning this research is in the review process at Molecular Metabolism. In the third part of my PhD research efforts, I have found that in the BAT of young LP progeny several miRNAs are robustly downregulated. We have focused on let-7cp and miR-22-3p, which have the most severe decrease in expression. Our key finding is that these two miRNAs act synergistically to hinder mature brown adipocyte thermogenic activity. This work is in the process of being finalized for publication. In conclusion, during my PhD training I have revealed several novel findings, which lead to a better understanding of BAT physiology and its dysregulation in situations eventuating in perturbed glucose homeostasis. While additional efforts are certainly needed, these contributions advance our vision to leverage BAT as a promising target for the prevention and/or treatment of metabolic perturbations associated to obesity and type 2 diabetes.

Bakgrund - Diabetes typ 2 är en folksjukdom som ökar kraftig globalt. Orsaken till diabetes typ 2 kan vara osund livsstil, ärftlighet och åldrande. Patienter som drabbas av sjukdomen har en stor risk att utveckla olika komplikationer vilket kan reducera livslängd. För att förebygga dessa problem behöver patienter med diabetes typ 2 kunskap om sjukdomen som kan leda till en hälsosammare livsstil. Syfte – Syftet med studien är att belysa vuxna patienters upplevelser av att leva med diabetes typ 2. Metod – Studien genomfördes som en litteraturöversikt grundad på nio insamlade vetenskapliga artiklar med en kvalitativ utgångspunkt. Databaserna CINAHAL och MEDLINE användes för att hämta de vetenskapliga artiklarna. Resultat- resultatet presenteras i fyra teman: Vardagliga utmaningar som orsakades av diabetes typ 2, Vikten av kunskap, Vikten av livsstilsförändringar, Behov av andras stöd. konklusion - Sjuksköterskor och-övriga inom sjukvården kan uppfatta patienters behov genom att ha förståelse för patienters upplevelser med att leva med diabetes typ 2. Detta kan hjälpa dem att erbjuda patienter en individanpassad och personcentrerad vård. Att ha nya rutiner i vardagen kan stödja patienter med diabetes typ 2 att kunna hantera sjukdomen samt anpassa sig till de nya levnadsvanorna. / Background- Type 2 diabetes is a common disease that is increasing drastic globally. The cause of type 2 diabetes can be unhealthy lifestyle, heredity and aging. Patients who suffer from the disease have a high risk of developing various complications which can reduce life expectancy. To prevent these problems, patients with type 2 diabetes need knowledge about the disease that can lead to a healthier lifestyle. Aim- The aim of the study is to illustrate adult patients’ experiences of living with type 2 diabetes. Method- The study was conducted as a literature review based on nine collected scientific articles with a qualitative starting point. The CINAHAL and MEDLINE databases were used to retrieve the scientific articles. Results- The results presents in four themes: Everyday challenges caused by type 2 diabetes, The importance of knowledge, The importance of lifestyle changes, Need for support from others. Conclusion- Nurses and others in healthcare can understand patients’ needs by having an understanding of patients’ experiences of living with type 2 diabetes. This can help them offer patients a personalized and person-centered care. Having new routines in everyday life can support patients with type 2 diabetes to be able to manage the disease adapt to the new lifestyles.

Diabetes Mellitus typ 2 är ett vanligt och allvarligt folkhälsoproblem på global nivå. Sjukdomen uppkommer ofta till följd av ohälsosamma levnadsval som fysisk inaktivitet och osund kosthållning. Egenvård i syfte att stärka individers självkontroll och förändring av ohälsosamma levnadsvanor är därför en central del av diabetesvården. E-hälsa är ett tidsaktuellt hjälpmedel som kan användas för att identifiera hälsorelaterade behov och därmed stärka egenvården. Syftet med litteraturöversikten var att sammanställa aktuell forskning om hur individer med Diabetes Mellitus typ 2 upplever användandet av e-hälsa som stöd för egenvård i det vardagliga livet. Metoden är en systematisk litteraturöversikt baserad på 11 artiklar varav nio med kvalitativ design och två med mixad design. I resultatet framkom det att e-hälsa kan stödja individers egenvård på flera sätt; för att uppnå medvetenhet och acceptans i sjukdomen, för motivation till livsstilsförändring, för att involvera personer i omgivningen och för att kommunicera med hälso- och sjukvård. Deltagarna i studierna beskrev positiva upplevelser av e-hälsa. E-hälsa är ett bra stöd för egenvård vid Diabetes Mellitus typ 2 och ett komplement till den redan befintliga diabetesvården. Förslag till framtida arbete är vidare utbildning inom e-hälsa till såväl vårdpersonal som individer. / Type 2 Diabetes Mellitus is a worldwide common and serious public health problem. The disease often arises as a result of unhealthy lifestyle choices such as physical inactivity and unhealthy diet. Self-care is therefore a central part of diabetes care in order to strengthen individuals self-control and to change unhealthy lifestyles. E-health is a modern tool that can help identify health related needs and thereby support selfcare. The aim of the literature review was to compile current research on how individuals with Type 2 Diabetes Mellitus experience the use of e-health as support to self-care in everyday life. The chosen method is a literature review based on 11 articles, of which nine has a qualitative design and two has a mixed design. The results showed that e-health can support everyone’s self-care in several ways; to achieve disease related awareness and acceptance, motivation in lifestyle change, involving people in the environment and to communicate with health care providers. The participants described positive experiences of e-health. E-health is a relevant support for self-care management in Type 2 Diabetes Mellitus and a complement to the existing diabetes care. A proposal for future work is further education in e-health for both health care providers and individuals.

Bakgrund: Diabetes typ 2 är en växande folksjukdom världen över. Sjukdomen kan leda till olika komplikationer och för tidig död. För att förebygga detta krävs det att patienter utför egenvård i form av livsstilsförändringar, som till exempel fysisk aktivitet och hälsosam kost. För att göra patienter delaktiga krävs det att sjuksköterskor informerar, motiverar och stärker dem i sin egenvård. Syfte: Syftet var att belysa patienters upplevelser av faktorer som påverkar delaktighet i sin egenvård vid diabetes typ 2. Metod: En litteraturöversikt baserat på tio kvalitativa vetenskapliga artiklar. Resultat: Patienter upplever att kunskap och utbildning, aktiviteter i grupp, relationen mellan patienter och sjuksköterskor, stödjande nätverk samt livssituationen påverkar delaktighet i sin egenvård vid diabetes typ 2. Kunskap och utbildning ökar patienters förståelse och ökar självförtroende att utföra egenvård. En god relation mellan patienter och sjuksköterskor bidrar till patienters egenvårdshantering. Stödet från sjuksköterskor, familj och e-hälsa upplevs vara motiverande till patienters egenvård. Livssituationen påverkar patienters egenvårdsbehov samt motivation, vilket är varierande under livets olika faser. Konklusion: Patienter med diabetes typ 2 upplever att fysiska möten med sjuksköterskor är viktiga för att ge en motiverande effekt på egenvård. För att öka delaktighet behöver sjuksköterskor se till patienters livsvärld och anpassa vården utefter patienters individuella behov. / Background: Type 2 diabetes is a growing public disease worldwide. The disease can lead to various complications and premature death. To prevent this, patients are required to perform self-care in the form of lifestyle changes, such as physical activity and a healthy diet. In order to involve patients, nurses need to inform, motivate and strengthen them in their self-care. Aim: The purpose was to shed light on patients' experiences of factors that affect participation in their self-care in type 2 diabetes. Method: A literature review based on ten qualitative scientific articles. Findings: Patients experience that knowledge and education, group activities, the relationship between patients and nurses, support networks and life situation affect participation in their self-care in type 2 diabetes. Knowledge and education increase patients' understanding and increase self-confidence to perform self-care. A good relationship between patients and nurses contributes to patients' self-care management. The support from nurses, family and e-health is perceived as motivating patients' self-care. The life situation affects patients' self-care needs and motivation, which varies during different phases of life. Conclusion: Patients with type 2 diabetes experience that physical meetings with nurses are important in order to have a motivating effect on self-care. To increase participation, nurses need to look at patients 'worlds of life and adapt care according to patients' individual needs.

Bakgrund: Diabetes typ 2 är en ökande folksjukdom som obehandlat eller felbehandlat kan resultera i komplikationer och följdsjukdomar. Det ställer höga krav på individens följsamhet med att sköta sin egenvård. Sjuksköterskan har ett väsentligt ansvar för omvårdnadsarbetet och påverkan på följsamheten för patienten. Syfte: Syftet med denna litteraturöversikt är att undersöka patienters upplevda barriärer till självadministrering av insulin vid diabetes typ 2, för att öka kvalitén i omvårdnadsarbetet. Metod: En allmän systematisk litteraturöversikt över kvalitativa artiklar med tematisk analysmetod Resultat: Två huvudteman kunde identifieras Komplexitet och Rädsla, samt 5 subteman, Införliva, Kostnad, Nålrädsla, Riskfyllt och Sociala värderingar. Resultatet visade att Införliva och Riskfyllt som subteman var de barriärer som uppkom flest gånger. Slutsats: Flertalet barriärer finns som sjuksköterskan kan rikta omvårdnadsarbetet mot för att stärka patienten i sin egenvård. Framtida forskning behöver särskilja perorala läkemedel och insulin inom följsamheten för tydligare resultat. / Background: Type 2 diabetes is a growing public disease that, if left untreated or mistreated, can result in complications and further diseases. It places high demands on the individual with their self-care. The nurse has an essential responsibility for the nursing care and can have an impact on the patient's compliance. Aim: The aim of this literature review is to explore patients' perceived barriers to self-administration of insulin in type 2 diabetes, in order to increase the quality of nursing care. Method: A general systematic literature review of qualitative articles with a thematic analysis method. Results: Two main themes were identified: Complexity and Fear, and five sub-themes, Incorporating, Cost, NeedlefearPerilous and Social values. The results showed that Incorporating and Perilous as a subtheme were the most mentioned barriers. Conclusions: There are several barriers that the nurse can direct the nursing care towards in order to strengthen the patient in their self-care. Future research needs to differentiate oral drugs and insulin within compliance for better results.

No abstract available. / Dissertation (MSc)--University of Pretoria, 2013. / gm2014 / Clinical Epidemiology / unrestricted

Bakgrund: Antalet personer med diabetes mellitus typ 2 är ett globalt växande problem. Målet med behandlingen är normala blodsockernivåer och egenvård är en viktig del av behandlingen. Många personer med diabetes mellitus typ 2 upplever stigma av diagnosen. Stigmat upplevs i det sociala livet och på arbetsplatsen.  Syfte: Syftet var att belysa för sjuksköterskan vilken inverkan stigma av diabetes mellitus typ 2 har på vuxna med diabetes mellitus typ 2.  Metod: En litteraturöversikt. 16 vetenskapliga artiklar hämtade från databaserna CINAHL, Pubmed och PsycINFO användes till grund för resultatet.  Resultat: Fem teman framkom i resultatet. Känslomässig inverkan, viljan att gömma sin diagnos, strategier för att gömma sin diagnos, inverkan på sociala livet och inverkan på egenvården.  Slutsats: Den negativa inverkan som stigmat har på personer med diabetes mellitus typ 2 skulle kunna orsaka en kaskadeffekt som grundar sig i en negativ inverkan på det känslomässiga, som i sin tur leder till en negativ inverkan på det sociala livet och egenvården. Sjukvården har en betydande roll i hur personer upplever stigma av diabetes mellitus typ 2. Genom att belysa den negativa inverkan stigmat har, kan hälso- och sjukvårdspersonal anpassa vården till patienten och därmed bidra till en ökad vårdkvalitet och främja hälsa för personer med diabetes mellitus typ 2. / Background: The number of people with type 2 diabetes mellitus is a globally growing issue. The goal with treatment is normal blood sugar levels and self-care is an important part of treatment. Many people with type 2 diabetes mellitus experience stigma of the disease. Stigma is experienced in the social life and in the workplace.  Aim: The aim of this study was to illuminate to the registered nurse what affect stigma of type 2 diabetes mellitus has on adults with type 2 diabetes mellitus.  Method: A literature review. 16 articles retrieved from the databases CINAHL, Pubmed and PsycINFO have been the basis for the objective.  Results: Five themes emerged in the result. Emotional affect, the will to hide the diagnosis, strategies to hide the diagnosis, impact on the social life and impact on the self-care.   Conclusion: The negative affect that stigma has on people with type 2 diabetes mellitus could cause a cascade affect that is based on a negative affect on emotions, which leads to negative affects on the social life and self-care. Health care has a significant role in how people experience the stigma of type 2 diabetes mellitus. By illuminating the negative affect that stigma has, healthcare professionals can adjust the care to the patient and contribute to a care with higher standard and enable good health for people with type 2 diabetes mellitus.