ORIGINAL RESEARCH

published: 17 February 2022

doi: 10.3389/fendo.2022.771293

A Qualitative Exploration of Self-

Management Behaviors and
Influencing Factors in Patients
With Type 2 Diabetes
Xi Peng 1†, Xinhong Guo 1†, Hongmei Li 1, Dan Wang 2*, Chenxi Liu 3 and Yaling Du 1
1 First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China, 2 School of Management, Hubei University of

Chinese Medicine, Wuhan, China, 3 School of Medicine and Health Management, Huazhong University of Science and
Technology, Wuhan, China

Background and Aims: The self-management behavior of patients with diabetes involves a
complex set of actions involving medication therapy, lifestyle changes, and management of
complications in the daily routine. Our study aims to explore adherence to self-management
Edited by: behaviors by patients with type 2 diabetes and the potential factors influencing those behaviors.
Hans Ulrich Häring,
University of Tübingen, Germany Methods: This qualitative study used semi-structured interviews conducted with patients
Reviewed by: who have type 2 diabetes and who were recruited from the department of endocrinology in
Aixia Sun, a tertiary teaching hospital. Data were analyzed thematically using the interview framework.
Michigan State University,
United States Results: Overall, 28 patients with type 2 diabetes were recruited and interviewed. Three
Rick I. Meijer, types of medication noncompliance behaviors were coded. In particular, blindly optimistic
Radboud University Nijmegen
Medical Centre, Netherlands
attitudes toward the condition in younger patients who had a short duration of diabetes
*Correspondence:
and fear of or pain from medication therapy were key influencing factors. Irregular
Dan Wang monitoring and missed follow-up visits were the most frequently mentioned
[email protected]
noncompliance behaviors. Poor understanding of blood glucose monitoring, selective
†
These authors share first authorship
ignorance due to pressure of uncontrolled blood glucose, and blindly optimistic attitudes
Specialty section:
were also identified as key influencing factors. Dietary behaviors were characterized by an
This article was submitted to overemphasis on the amount of food in the diet and the preference or declination for
Clinical Diabetes, particular types of food; ignorance of the dietary structure was present. Misconceptions
a section of the journal
Frontiers in Endocrinology about dietary and exercise practices were the main types of lifestyles’ noncompliance.
Received: 06 September 2021 Conclusion: Our study showed the complex picture of noncompliance with self-
Accepted: 26 January 2022
management behaviors by patients with type 2 diabetes. Noncompliance covered
Published: 17 February 2022
disordered and arbitrary changes in medication therapy, blood glucose monitoring with
Citation:
Peng X, Guo X, Li H, Wang D, Liu C poorest adherence, lifestyle modifications and complication management. The study findings
and Du Y (2022) A Qualitative identify clear challenges to self-management behavior and identify potential key influencing
Exploration of Self-Management
Behaviors and Influencing Factors in
factors. Future interventions and strategies should aim to help patients translate healthcare
Patients With Type 2 Diabetes. provider’s information and instructions into action that improve compliance.
Front. Endocrinol. 13:771293.
doi: 10.3389/fendo.2022.771293 Keywords: qualitative study, diabetes patients, self-care, noncompliance behavior, influencing factors

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Peng et al. Self-Management of Diabetes Patients

1 INTRODUCTION understanding can improve strategies for teaching self-

management behaviors to patients with diabetes.
Diabetes has become a critical health concern worldwide. The
prevalence of type 2 diabetes is rising rapidly in lower- and
middle-income countries. In the long term, diabetes is
responsible for a substantial death and illness burden. A large 2 MATERIALS AND METHODS
national survey showed that an estimated 129.8 million people
2.1 Study Setting
live with diabetes in mainland China (1–3). The chronic progress
The study was conducted in one tertiary teaching hospital (First
of diabetes and its serious complications contribute to substantial
Affiliated Hospital of Shihezi University) in the western region of
socioeconomic and health burdens for individuals and health
China. In western China, the diabetes prevalence was at a high
systems (4).
level of approximately 10.64% to 11.93%, according to the results
Self-management is considered as the cornerstone of diabetes
of one national study (1). With relatively underdeveloped social
management. And self-management behavior has been proven
and economic levels, the western region has few resources for
to improve glycemic control and slow the progression or
diabetes education (14, 21).
development of complications (5). However, patients with
diabetes must follow a complex set of actions involving
medication therapy, lifestyle changes, and management of 2.2 Participants and Sampling
complications in the daily routine (6, 7). Adherence to self- Patients who were diagnosed with type 2 diabetes in the
management behaviors is far from satisfactory worldwide (8). department of endocrinology were recruited for interviews.
Why do patients with type 2 diabetes fail in adequate self- Participants were admitted to adjust medication therapy for
management practices? Existing studies have investigated the better control of type 2 diabetes or complications and receive
potential barriers associated with self-management in patients professional diabetes education. The participants were asked
with diabetes; these include inadequate information or about their self-management behaviors and especially about
knowledge about diabetes management and distress or deviations from recommended self-management behaviors.
insufficient social support (9–11). Some studies have explored There are two inclusion criteria in participants and sampling
the psychological factors that affect patients with diabetes, such section: Patients who were diagnosed with type 2 diabetes in the
as poor awareness, insufficient self-efficacy, and lack of department of endocrinology were recruited for the interviews.
motivation (12–15). Patients have had a type 2 diabetes diagnosis for at least 1 year,
Focusing on the practice or experience of self-management by have length of stay over 48 hours, have a willingness to talk
patients with diabetes, some qualitative studies have provided about their experiences with the interviewer, and give consent
insights into self-management behaviors and related dimensions, for to be audio recorded. Those who have communication
such as diabetes knowledge, family support, or life difficulties, such as significant impairment in vision, hearing
circumstances; these studies were conducted in target or speech (assessed by the interviewers) were excluded in
population in the Netherlands, Pakistan, and other countries the study.
(16, 17). The successful application of models or interventions Purposive sampling was applied to ensure that participants
depends not only on the distinctive characteristics of the target with different backgrounds, occupations, and disease durations
population but also on special contexts, such as culture or were included. The participants’ recruitment period lasted from
districts. More exploration of local self-management behaviors, June 1 to July 15 2021.
experiences, and key barriers is necessary.
The Chinese health system has run a series of national policies 2.3 Interview Framework and Data
and campaigns aimed at improving self-management in patients Collection
with chronic conditions (18); however, suboptimal self- The interview framework prepared for the participants
management behaviors are still prevalent (19). To date, several concerned self-managements behaviors and their key
quantitative cross-sectional studies have been conducted in influencing factors and was based on a literature review.
China to measure the status of self-management or explore the Multiple aspects of self-management—medication therapy,
relationship between knowledge about diabetes and blood glucose monitoring, follow-up visits, and lifestyle
psychological factors, such as health beliefs or self-efficacy (14, changes— were considered. The interviewer collected basic
19, 20). However, limited studies have been conducted to explore information— age, gender, diabetes duration, and occupation
in depth the feelings, experiences, and other potential factors — for each participant. The semi-structured interview
related to self-management in patients with type 2 diabetes framework was presented in Supplementary File 1.
in China.
Therefore, we developed this qualitative study to explore self- 2.4 Ethics Statement
management behaviors and provide insights into the experiences This study was approved by the ethics committee of the First
of potential barriers for Chinese patients with type 2 diabetes. Affiliated Hospital of Shihezi University Medical School (kj2020-
The results are key to improving the understanding about and 087-03), and it was part of one randomized control trial
resolving the gaps related to the failure of self-management (Effectiveness of Medication Reconciliation Intervention Led by
behaviors by patients with type 2 diabetes, and this better Clinical Pharmacists Based on Improved Model: a Randomized

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Peng et al. Self-Management of Diabetes Patients

Controlled Trial), which was registered in the China clinical trial the interview framework as medication therapy behaviors, blood
registry (www.chictr.org.cn, number chictr2000035321). glucose monitoring behaviors, dietary and exercise behaviors,
and management of disease complications (Table 1).
2.5 Statistical Analysis
Two authors (D.W. and X.P.) performed the verbatim 3.3 Theme 1: Suboptimal Medication
transcription of the audio recordings of interviews. The Therapy Behaviors, Trajectories, and
interview questions served as the basic framework of analysis. Influencing Factors
The data were analyzed qualitatively following the steps of After the initial diagnosis of type 2 diabetes, patients reported
content analysis. Two authors (C.X.L and D.W.) separately three types of noncompliant behaviors with respect to blood
coded all the interview data line by line using NVIVO glucose–lowering therapy. There were discontinuation of
software. They compared and classified the codes into similar medication therapy; arbitrary change of frequency, amount, or
themes and subthemes. Any discrepancies were discussed with duration of medication therapy; and use of supplemental
another expert on diabetes management until we agreed on a health products.
final list of themes and sub-themes (Table 1). No statistical tests
were conducted in this study. The qualitative analyses were 3.3.1 Discontinuation of Medication Therapy
conducted with NVIVO V.12.1 QSR International software. Approximately one-third of the participants (n=10) reported
discontinuation of medication, including oral tablets (e.g.,
metformin or acarbose) and insulin injections.
3 RESULTS 7 (Male, 51 years with diabetes of 3 years): After my initial
diagnosis at the hospital, the doctor gave me two oral tablets. I
3.1 Sample Profile stopped the medication after several months.
Overall, 28 patients with type 2 diabetes were recruited to be 9 (Male, 31 years with diabetes of 3 years): With the initial
interviewed. Among the 28 participants, 39% (n=11) were diagnosis of diabetes with the therapy of insulin injections and
female, and approximately 36% (n=10) were over 60 years old. oral tablets. After 1 year I stopped all the medication therapy.
The youngest participant was a 27-year-old female patient.
Diabetes durations ranged from 1 year to more than 30 years, 3.3.2 Changes to Medication Type, Amount, or
and approximately half of the participants (n=16) lived with Frequency of Therapy
diabetes for more than 10 years. Nine patients were diagnosed Arbitrary changes in the type, amount, or frequency of the
with type 2 diabetes less than 5 years before the interview. Six medication made by participants were coded. For example,
patients lived with other chronic conditions, such as changes from rapid-acting insulin to long-acting insulin
hypertension or heart disease. Most patients were retired injections or from a glucose-lowering oral tablet to insulin
(n=13), and other occupations included office workers (n=6) or injections were reported.
farmers (n=6). The detailed information was presented in 2 (Female, 78 years with diabetes of 20 years): The doctors
Supplementary File 2. recommended I use the rapid-acting insulin three times a day,
with the suggestions of diabetic friends, I bought the long-acting
3.2 Self-Management Behaviors and Key insulin for convenience.
Influencing Factors of Noncompliance 28 (Female, 48 years with diabetes of 10 years): When the
Behavior fasting glucose was higher and cannot reach the targets, I would
After identifying the themes and subthemes in this study, the increase every time….Last time, it was around 20 to 25 units for
self-management behaviors could be summarized according to each meal.

TABLE 1 | Thematic results of suboptimal self-management behaviors.

Themes Sub-Theme No. of Respondents

(n=28)

Suboptimal medication therapy behaviors Discontinuation of medication therapy 10

Arbitrary changes to medication type, amount, or frequency of therapy 7
Supplemental health products 2
Suboptimal blood glucose monitoring and follow-up visits Lack of regular glucose monitoring 27
behaviors Lack of 2-hour postprandial glucose monitoring 27
Lack of full-period glucose monitoring 28
Missed follow-up visits 27
Suboptimal dietary behaviors Overemphasis of amount of food 10
Preference or dislike of particular types of food (e.g. preference of coarse 6
grains)
Suboptimal exercise behaviors “Walking as the only way for exercise” 8
No consideration of activity intensity or consumption of calories 26
Suboptimal behaviors related to managing complications of Skincare of diabetic feet 3
diabetes Management of needles for insulin injections 3

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Peng et al. Self-Management of Diabetes Patients

26 (Female, 63 years with diabetes of 2 years): My friends told 3 (Female, 68 years with 15 years of diabetes): I always felt
me that oral tablets would cause renal damage, so I changed the that my blood glucose was not well controlled. I went to the
frequency from three times a day to twice a day. pharmacy. The pharmacy recommended buying the health
In addition, an arbitrary change to the amount of insulin products. I supplemented my medicine with health products.
should be empathized in elderly patients. 10 (Male,49 years with diabetes of 11 years): From 2017, I felt
not very good, and my vision weakened. I listened to others’
3.3.3 Adjustment to Medication Therapy in Elderly suggestions to take the traditional way. That was washing my
Participants body using herbs, such as ginger.
Many participants with a long duration of diabetes conditions
told the interviewer that they were familiar with insulin therapy 3.3.5 Trajectory of Suboptimal Medication Therapy
and that they knew how to tackle blood glucose fluctuations. For Behavior
example, when their measured blood glucose was a little higher Two distinctive trajectories of changing medication therapy were
or lower than the target, they would increase or decrease therapy coded in this study: a disordered and arbitrary way of changing
by one or two units of insulin. therapy seen in patients with relatively long durations of
However, patients, especially elderly patients, did not diabetes, and an early discontinuation of medication therapy
comprehensively understand insulin therapy, so increased seen in younger patients with short durations of diabetes.
insulin units would increase the risk of hypoglycemia or other The distinctive feature of a disordered and arbitrary way of
severe events, such as ketoacidosis. The following examples changing medication therapy was coded as follows: After the
demonstrate exaggerated increases in insulin units caused by initial diagnosis and medication therapy instruction by
misunderstandings about medication therapy. physicians, patients arbitrarily changed their medication
2 (Female, 78 years with diabetes of 20 years): With the products, frequency, or form without formal counseling. The
diagnosis of hypoglycemia…, when I measured that my blood first change to their medication therapy varied from several
glucose was higher than the normal times, I increased my insulin months to several years after the initial diagnosis of diabetes.
to 15 units (The original unit was 12) and try to eat less at that Rehospitalization was an important opportunity for receiving
meal. The interviewer: Why were you increasing your insulin at formal counseling again and for readjusting the medication
one time and reducing your intake simultaneously, that’s very therapy with a physician. The typical method for formal
dangerous. #2: If I did not do that, I cannot lower my adjustment of therapy in the hospital and the arbitrary change
blood glucose. by patients after discharge are illustrated in Figure 1.
22 (Male, 61 years with diabetes of 14 years): For the last 2 4 (Female, 61 years with 20 years of diabetes): After initial
years, I increased my insulin from 16 units to 40 units when my diagnosis of diabetes, I did not take any measures. My sister
fast blood glucose was not good. Interviewer: How can you helped me to buy oral glucose-lowering medication…4 to 5 years
increase your insulin in such a large amount? Have you seen a later, she asked me to go to the hospital to get insulin injections. I
doctor for your insulin treatment? #22: No, I modified the used that therapy for around 5 years, and I went to the hospital
amount by myself. I understood that I can increase my again for my heart disease. The doctor helped me change my
amount, so I increase one or two-unit each time … And it diabetic medication therapy.
reached 40 units. 22 (Male, 61 years with diabetes of 14 years): After initial
diagnosis at the county hospital, I ate the oral tablets by the
3.3.4 Supplemental Health Products doctor for around half a month, I changed to another medicine
Some patients, especially those who had a relatively long recommended by my diabetic friends. Later after 1 to2 years, I
duration of diabetes, referred to traditional Chinese medicine, changed to another medication. Then in 2015, I went to the
such as herbal medicine or health products, like bitter vegetables, hospital to start my insulin injection……Then I went to the
as a supplementary way to help them lower their blood hospital again for my stomachache, and my blood glucose was
glucose levels. not good, and the doctor helped me adjust my diabetic therapy.

FIGURE 1 | The vicious cycle of medication management of patients with a relatively long duration of type 2 diabetes.

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Peng et al. Self-Management of Diabetes Patients

23 (Male, 53 years with diabetes of 20 years): When I was first medicine? #21: Not for that reason. I just felt I was young, and
diagnosed, I did not take care of it for several years. Then I It was okay to stop the therapy.
started oral tablets around 10 years ago. Several years later I went
to the hospital to get insulin injections. Then I stopped my oral
3.3.6.2 Fear of or Pain From Medication Therapy and
tablets and increased my insulin units when the glucose was Roles of Diabetic Family Members and Friends
not good. The participants reported several reasons for noncompliance
Patients with a short duration of diabetes (less than 5 years) with medication. Fear or pain from the medication therapy was
tended to discontinue their medication therapy at an early stage the most frequently reported barrier to medication adherence.
after the initial diagnosis of diabetes. The time to discontinuation Unsatisfactory glucose-lowering effects, the inconvenience of
varied from several months to approximately 1 year after the insulin injections, occupation limitations, and economic
initial diagnosis. burden were also mentioned as reasons for noncompliance.
7 (Male, 51 years with diabetes of 3 years): After my initial 3.3.6.3 Adverse Effects of Medication Therapy
diagnosis at the hospital, the doctor gave me two oral tablets. I Most participants chose to change or discontinue medication
stopped the medication after several months. therapy because of adverse effects from the medication therapy.
9 (Male, 31 years with diabetes of 3 years): With the initial Examples include stomachache caused by the oral tablets and
diagnosis of diabetes. I had the therapy of insulin injections and fear or nervousness caused by the insulin injections.
oral tablets. After 1 year I stopped all the medication therapy. 10 (Male,49 years with diabetes of 11 years): At that time, I
15 (Female, 27 years with diabetes of 2 years): I initially took took the insulin injections therapy. However, it was painful to
the metformin and acarbose and insulin injection. However, take the injections. I was so nervous, so I stopped the insulin.
when I felt the stomachache, I stopped the oral tablets. Later I 16 (Female, 76 years with diabetes of 15 years): I felt so hard
stopped the insulin injection. in my belly, so I discontinued the oral therapy and only took the
insulin injections.
3.3.6 Factors Influencing Noncompliance to 17 (Male, 56 years with diabetes of 9 years): The doctor asked
Medication Therapy me to take insulin injections. When I went home, it felt weird to
3.3.6.1 “Feeling Good” as a Reason for Discontinuing take the insulin injections and felt like something was pressing
Medication by Younger Participants With Diabetes me, so I stopped the insulin.
Duration Less Than 5 Years
Participants especially those who were young and had diabetes 3.3.6.4 Roles of Diabetic Friends and Family Members
for a short time said they “felt good with their conditions” as the Friends and family members with diabetes were important
reason for discontinuing their medication therapy. No specific references for changing medication therapy. Participants told
criteria for good control of their conditions were reported. The interviewers that they trusted and followed the suggestions of
participants emphasized their subjective feelings or the easing of friends or family members with diabetes to make changes in the
their symptoms. When they were asked whether their blood forms, frequencies, or amounts of medication therapy or to
glucose levels were assessed, the responses were negative. Youth supplement therapy with new health products, such as ginger
was mentioned as one reason for arbitrarily discontinuing or bitter vegetables, without formal counseling.
medication therapy. The young participants thought they could 4: When I have first diagnosed with diabetes, I did not tackle
tackle the situation without medication therapy. As a result of the problem. And when my sister (who was a diabetes patient)
their self-perceptions, blood glucose monitoring, regular follow- asked me to give attention to diabetes and helped me buy the
up visits, and lifestyle modifications were usually abandoned. medicine that she used.
7 (Male, 51 years with 3 years of diabetes): When initially 22 (Male, 61 years with 14 years of diabetes): With the
diagnosed with diabetes with oral tablets therapy. When I took suggestions of my diabetic friends, I bought oral tablets from
that therapy for a while, I feel good, so I stopped the the pharmacy. Later my diabetic friends told me that oral tablets
medication therapy. would cause renal damage, so I went to the hospital to get
9 (Male, 31 years with diabetes of 3 years): With the initial insulin injections.
diagnosis of diabetes with the therapy of insulin injections and 10 (Male, 49 years with diabetes of 11 years): When I found
oral tablets. After 1 year I felt very good, so I stopped all the that I cannot control my blood glucose well. With the
medication therapy. suggestions of my friends, I started to “Paojiao” with hot water.
15 (Female, 27 years with diabetes of 2 years): I initially took
the metformin and acarbose and insulin injection. However, 3.4 Theme 2:Suboptimal Blood Glucose
when I felt the stomachache, I stopped the oral tablets. Later I felt Monitoring and Follow-Up Behavior and
I was Okay … I had no symptoms of thirst or tiredness, I stopped Influencing Factors
the insulin injection. 3.4.1 Suboptimal Blood Glucose Monitoring
21 (Male,47 years and with diabetes of 9 years): The initial Compared with other dimensions of self-management behavior,
treatment therapy 9 years ago was acarbose and I ate for 1 month participants showed the worst adherence to blood glucose
and stopped therapy. Interviewer: Why you stopped your monitoring. Most participants lacked consistent monitoring and
therapy? For the effects were not good or the cost of the regular follow-up visits regardless of the duration of diabetes.

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Peng et al. Self-Management of Diabetes Patients

Although almost all the participants expressed that they had Not knowing the importance of the 2-hour postprandial
bought a blood glucose meter to measure their blood glucose blood glucose level or not taking the postprandial blood
freely at home, only one of them (#13) had the habit of regular glucose measure seriously was reported as the reason for
fasting blood glucose monitoring. Most patients only measured skipping the postprandial blood glucose measurement.
the fasting blood glucose level; the 2-hour postprandial blood For example, one participant (Female, 54 years with diabetes
glucose level was rarely measured, despite its importance in of 10 years) said that she did not know about the 2-hour
guiding medication therapy and lifestyle changes. No participant postprandial blood glucose level, despite having diabetes for 10
measured full-period blood glucose levels at home (three fasting years and being educated by diabetes coaches in the hospital.
glucose measures before a meal, three glucose measures after a Some participants lacked accurate criteria to target their
meal, and one measure before bedtime). blood glucose level and felt good about their present blood
1 (Male, 59 years and with 10 years of diabetes): Basically, I glucose level. They did not adjust their behavior when they
measured my fasting blood glucose once a week and I rarely perceived the blood glucose was “good and acceptable”.
measured the 2-hour postprandial blood glucose. 9 (Male, 31 years with diabetes of 3 years): After I stopped my
12 (Female, 56 years with diabetes of five years): When I was insulin, I seldomly measured my blood glucose. It was around 10
getting discharged, I usually frequently measured my blood to 11 mmol/L and It was only a little bit higher than the normal
glucose, however, after that period, I feel it was okay and I level. It is Okay.
seldom measured my blood glucose. I measured the fasting blood 28 (Female 48 years with diabetes of 10 years): Sometimes, the
glucose and postprandial blood glucose was rarely measured. fasting blood glucose was around 10 mmol/L. It was Okay
15 (Female, 27 years with diabetes of 2 years): When I have and acceptable.
first diagnosed with diabetes 2 years ago, I never went to the
hospital and I never measured my blood glucose.
3.4.3.2 Stress or Anxiety Related to Uncontrolled Blood
Glucose Level
Patients, especially those with poorly controlled diabetes,
3.4.2 Follow-Up Behavior
indicated that they purposely ignored their blood glucose
The lack of regular formal follow-up visits was also typical. For
measurements. One participant (Male, 53 years with 20 years
some participants, follow-up visits with formal medical
of diabetes) expressed that “I knew that my blood glucose control
counseling were missed for 4 to 5 years. Participant #28 had
was poor, and I already measured the fasting blood glucose. The
not attended a follow-up visit for almost 10 years since the initial
postprandial blood glucose was higher, and I did not want to know
diagnosis of diabetes. Most participants were rehospitalized after
the high blood glucose level after meal … it was maybe pressure
their initial diagnoses because of acute conditions, such as
for me”.
fainting, ketoacidosis, or acute heart failure. Because blood
20 (Male, 66 years with 30 years of diabetes) “Everyone did
glucose monitoring was inconsistent and follow-up visits were
not like measuring postprandial blood glucose, measuring
missed, adequate control of blood glucose could not
postprandial blood glucose was not important … And it was
be ascertained.
difficult for me to insist on measuring fast blood glucose every
16: With the initial insulin treatment by the physicians, I did
day, not to mention postprandial blood glucose”.
not go to the hospital and adjust the treatment for around 4 to 5
years, I did not come to the hospital because my husband was ill 3.4.3.3 “Feeling Good”
and I had no time to hospital. Surprisingly, “feeling good” again was another contributor to
17 (Male, 56 years and with diabetes of 9 years): I only had an noncompliance with blood glucose monitoring in younger
insulin injection at the hospital and stopped the insulin therapy participants with short durations of diabetes. Several
at discharge. From 2018 on, I never came to the hospital and did participants who had a diagnosis less than 5 years stated that
not get any tests of my blood glucose. And I came hospital this they started to reduce the frequency of monitoring the blood
time because my feet skin gets darker, and I am a little afraid. glucose and skipped the necessary follow-up when they felt good.
25 (Female, 58 years with diabetes of 15 years): I was in They followed the initial therapy without additional monitoring
another city for around 3 to 4 years so I did not go to the hospital. of blood glucose levels or regular follow-up visits (22). Thus, the
I came here this time because my feet were rotten. actual blood glucose level was not measured.
12 (Female, 56 years with diabetes of 5 years): I kept using the
3.4.3 Factors Influencing Noncompliance With Blood initial medication therapy and I felt good. It is Okay When I felt
Glucose Monitoring and Follow-Up Visits wrong, I would remeasure my blood glucose.
3.4.3.1 Lack of Understanding of Blood Glucose Monitoring 19 (Male, 55 years with diabetes of 5 years): From 2016, I still
Poor understanding about glucose monitoring was the most used the medication therapy 5 years ago and never went to the
frequently mentioned contributor for noncompliant behavior. hospital for follow-up. I feel good so I kept this therapy.
One participant (#4 Female, 68 years with diabetes of 20 years) Interviewer: What is the meaning of good? Have you measured
expressed that “Collecting full period blood glucose in a day was your blood glucose? #19: It was just the feeling, I did not monitor
the duty of the hospital, I only need to measure the fasting blood my blood glucose consistently and only measured when a
glucose, it was very important”. problem occurred.

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Peng et al. Self-Management of Diabetes Patients

3.4.3.4 “No Severe Problems or Accidents Occurred” less, I can lower my blood glucose.” Several patients expressed
With poor knowledge of and awareness about diabetes, the confusion, saying that “I am eating only a bit of the food. What’s
participants perceived that “diabetes did not threaten their wrong with me? Why I still cannot control my glucose?”.
daily life in a long-term way”. As long as no severe problems
occurred, the patients with relatively long durations of diabetes 3.5.2 Preference or Dislike of Particular Types of
did not have regular follow-up visits. Food
23 (Male, 53 years of 20 years of diabetes): Interviewer: Did The participants preferred to modify their eating habits by choosing
you know your diabetes was not controlled well? Why did you food containing coarse grains or oats, such as corn, oatmeal, beans,
not come to the hospital? #23: Yes, it was not good. Interviewer: which were identified as healthy foods. Sometimes they disliked one
What did you mean good? #23: Good control of diabetes means particular food, such as meat or the carbohydrate. Meat seemed to
no severe accidents occurred. become a burden for the patients. Some food (e.g., tomatoes or
cucumbers) were considered the best by some patients; they
3.4.3.5 Blood Glucose Measurement Method believed these foods contained no calories, they could eat as much
The method used to measure blood glucose (by collecting of them as they wanted (#8, Male, 49 years with diabetes of 20 years;
fingertip blood) also affected participants’ willingness to #11, Male, 57 years with diabetes of 3 years).
measure the full period blood glucose.
16 (Female, 76 years with diabetes of 15 years) “Unlike blood
3.5.3 Structure of Food
press measuring, measuring the blood glucose hurts. When I
The food structure was rarely mentioned by the participants. The
went to the community center, I would ask the nurses to help
necessary protein would usually be ignored and the match of the
measure my blood glucose, other times I would not”.
nutrition elements, such as carbohydrate, fat, or protein, was
not considered.
3.5 Theme 3: Noncompliance With Diet
and Influencing Factors
Almost all the participants expressed that they understood the
3.5.4 Influencing Factors on Dietary Noncompliance
The misconceptions about diet contributed to an inappropriate
principles of “less eating and more exercise.” The majority of
dietary structure for patients with diabetes, resulting in
participants said that they modified the dietary aspects in their
insufficient protein intake or negative events like hypoglycemia.
daily lives, but some patients (n=5) would not change their
The frequently mentioned misconceptions about diet are listed
dietary habits because of occupation or other limitations. The
in Table 2. For example, the participants overemphasized the
following are examples of patient responses.
intake of less food as the perceived “right way” to control blood
9 (Male, 31 years with diabetes of 3 years): As our team
glucose. Participants were overly focused on particular foods
ordered the meal together, I had to eat the same food with others.
they liked or disliked, rather than on nutritional content.
The food the company ordered was always very greasy and
The specific eating habits during hospitalization was also
not healthy.
mentioned by participants. For example, participant #20
14 (Male, 39 years with diabetes of 1 year): When I ate with
reported that “I was afraid to eat too much at the hospital for
my coworkers, and I used to follow others’ dietary habits. And I
fear of blame by the doctors. Maybe I would eat more when I go
always ate more food than I was alone.
home. But now I have to control my intake in the hospital”.
Three major characteristics of dietary behavior were
presented as subthems: amount, preference or dislike, and
structure of food. 3.6 Theme 4: Suboptimal Exercise
Behaviors and Influencing Factors
3.5.1 Amount of Food Most participants preferred exercise modifications. However, few
The amount of the food was overemphasized by the majority of patients followed the recommendations of exercise behavior.
the participants. The participants perceived that “As long as I eat Most participants older than 60 years old expressed the

TABLE 2 | The main misconceptions according to the characteristics of the dietary noncompliance behavior.

Dietary noncompliance Examples

behavior

The amount of the food #2: I am afraid to eat too much. I always keep in mind to eat less. Diabetes patients should eat less.
9 I did not control my dietary amount before, but now I have to control my amount of food to better control my blood glucose … but I
felt a little hungry these months.
10(Male, 49 years and with diabetes of 11 years). I reduced half of my dietary intake for lowering my blood glucose…
The particular choice of Preference:
food 3(Female, 68 years and with diabetes of 15 years): I like to eat noodles with barley and corns. The barley and corns are good.
11(Male, 57 years with 3 years of diabetes): I usually would eat steamed buns with elements of coarse grains. It is good for health.
20: I would like to eat porridge with vegetables. The vegetables in porridge are good.
Dislike:
9: I used not control my amount of intake. Later I took it seriously, and I controlled my intake and especially ate less meat……
19: I would eat less meat because I am diabetic. Yesterday I ate vegetables, two steamed buns. I did not eat the meat……

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Peng et al. Self-Management of Diabetes Patients

worries that “I would feel my knees hurt If I kept walking, so I can However, the water temperature and duration of “Paojiao”
only eat less and do no exercise”. varied from person to person. The lack of knowledge about
2: When I was over 60 years old, I cannot do the activity as I skin protection was coded in this study. The participants usually
was younger. I could only walk slowly for around one hour. And expressed that they did not consider their skin to be fragile, so
later my knees hurt, and I cannot do the walking, and I had no they just used the “Paojiao” as one good and healthy activity for
way to do the exercise. relieving the numbness of their feet.
In patients younger than 60 years without physical 17 (Male, 56 years with diabetes of 9 years): I always felt that
limitations, participants indicated that “I should walk more, my feet were numb so I would do the “Paojiao” with hot water. I
that is good for me”, and only 2 participants mentioned that never considered that the high temperature will hurt my skin.
they considered other types of aerobic exercise or resistance
exercise as useful examples of exercise (#12, Female, 56 years 3.7.2 Management of Needles for Insulin Injections
with diabetes of 5 years, Table tennis exercise; #14, Male, 39 years The replacement of insulin needles was one behavior that
of diabetes of 1 year, resistance exercise). No patient mentioned deviated from the physicians’ instructions.
activity indicators, such as activity intensity or consumption 3 (Female, 68 years with diabetes of 15 years): When the
of calories. needles cannot pierce my belly, I would choose to change the
needle. I did not know what was the right frequency to replace
3.6.1 Occupational Limitations as Influencing Factors the needles.
on Suboptimal Exercise Behavior 16 (Female, 76 years with diabetes of 15 years): I knew it was
Participants with specific occupations, such as farmers or drivers, the disposal of the needle. But it was a waste if I just used it
or participants with habits of overwork, usually indicated the once…, so I chose to use the needle as long as I can, and
limitations of exercise behavior modification. sometimes I could feel the needle and it curled in my belly.
6 (Male, 52 years with diabetes of 11 years): Because I was a
farmer, so I had a large number of farming activities in summer
and much less activity in the winter. I cannot change the amount
4 DISCUSSION
of activity.
13: I was very busy with my daily work, and the overtime This study provides a complex picture of noncompliant self-
work usually existed, so I had no time to do the activity. management behaviors by patients with type 2 diabetes, covering
multiple aspects of medication therapy, lifestyle changes, and
3.6.2 Misconceptions About Exercise Behavior disease complications.
Similarly, the frequently mentioned barrier to appropriate There is great variability not only in the noncompliant
exercise, especially in patients older than 60 years, was behaviors related to medication therapy but also in the key
misunderstanding about exercise goals. Most of the elderly influencing factors contributing to the noncompliant behaviors.
patients understood the need for more exercise and were An arbitrary and disordered way of changing the medication
willing to do the exercise. However, they perceived that therapy was one emerging theme in patients with a relatively
“Walking was the only effective way for exercise, and they could long duration of diabetes. The adverse effects of pain or fear
not do the exercise as they were old and their knees would feel pain caused by medication therapy and the corresponding references
if they kept walking, so they felt very depressed”. to friends with diabetes have been frequently reported as
Younger patients mentioned, not knowing or understanding significant reasons for changing medication therapy (6, 23). A
that “the consumption of calories by exercise should be considered, proportion of the participants noted that diabetes did not
which is related with the intensity, frequency, timing and other threaten their daily life, and they only referred to physicians
medication-related and dietary-related indicators (such as units of when they were severely ill. An arbitrary change would be
insulin, dietary intakes)” as one reason for their exercise behavior rational for them, because they reported that they were
modifications. For example, participant #28 said that: “I would familiar with their condition and believed they could handle
walk after the meal. I knew that exercise was good for me. Walking the situation without formal medical counseling (24). It was
was the recommended way. I knew nothing about other aspects of likely that a lack of trust in healthcare providers is one potential
exercise behavior”. contributor to nonadherence to medication therapy, as noted in
previous studies (25, 26); for example, mistrust and tense
3.7 Theme 5: Behaviors and Influencing relationships exist between physicians and patients in
Factors Related to Managing China (27).
Complications of Diabetes In particular, “feeling good” without a formal medical
3.7.1 Skincare of Diabetic Feet diagnosis was one prominent reason that patients, especially
Diabetes-related skincare was one risk-reducing behavior for the younger patients with a short duration of diabetes,
ignored by the participants in this study. The participants with discontinued medication therapy. In our study, the younger
diabetic feet mentioned that “I felt my feet numb and I should participants always emphasized that they were young, and they
take a foot bath”. The “Paojiao” (a kind of foot bath) was one felt good after a short duration of medication therapy. Diagnosis
traditional way used to relieve the pain and numbness of feet. denial, and thus modification of medication use is plausible

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Peng et al. Self-Management of Diabetes Patients

among young patients (28, 29). One qualitative study showed Professional nutritional and exercise education is necessary for
that, as time progressed and no problems occurred, patients all patients with diabetes, especially because busy physicians
(especially for patients who were diagnosed less than 5 years seem to have insufficient time to explain the principle of “eat
before) stopped actively managing their diabetes. Patients with a less and walk more” in detail.
short duration of diabetes, especially younger patients who may Our findings also revealed that skincare was ignored by most
have fewer comorbid conditions, would be less susceptible to patients with the complication of diabetic feet. The traditional
diabetes complications (30). Chinese healthy activity “Paojiao” (a kind of foot bath) was one
It is of great importance for young patients with diabetes to popular activity for relieving the numbness of the diabetic feet.
understand the need for self-management as soon as possible. However, “Paojiao” may risk damaging fragile skin, if the water
Young adults are developing complications from diabetes in their temperature is too high1. Management of the needles was
early 20s, so identifying strategies and interventions to improve another concern, especially in elderly patients. The instructions
self-management in these patients is crucial (31). to change needles regularly seemed wasteful to them; however,
Our findings also showed that almost all the participants the inappropriate use of needles increased the pain or fear of
lacked consistent blood glucose monitoring and regular follow- insulin injection and accordingly, negatively affected their
up visits. Although healthcare providers always emphasize the adherence to medication therapy.
importance of 2-hour postprandial blood glucose measurement, There were some limitations to this study. First, this study was
the majority of patients measured fasting blood glucose and qualitative and had a small sample with a broad range of disease
selectively forgot to measure postprandial blood glucose. Such a durations so the results should be interpreted with caution
finding was demonstrated in a previous study, conducted in the considering the generalizability of the findings. A larger group
middle of China, as well; it showed that, compared with other of patients, or a more homogeneous group should be recruited
self-management behaviors, blood glucose monitoring was the in future studies. Second, there was potential sample selection
behavior with the lowest adherence (19). Poor understanding bias, because the respondents were all recruited from the
about how to consistently measure blood glucose each day was same department.
the most frequently reported factor leading to missed
postprandial blood glucose measurements (19).
However, as one qualitative study indicated, family obligations 5 CONCLUSIONS
(caring for family members) and long waiting times (at busy
tertiary hospital) were mentioned as the reasons for missing Our study showed a complex picture of noncompliant self-
follow-up visits (32). Specifically, younger patients with a short management behaviors in patients with type 2 diabetes. The
time since diabetes diagnosis showed blindly optimistic attitudes disordered and arbitrary changes to medication therapy in
toward their condition, and this optimism is a potential contributor patients with a relatively long duration of disease and
to the absence of regular follow-up visits (24). Without consistent discontinuation of medication therapy in younger patients with
glucose monitoring and regular follow-ups, it is hard for the a short duration of diabetes were two distinctive suboptimal
patients to understand their blood glucose levels and evaluate the medication behavior. Blood glucose monitoring and regular
efficacy of their medication. Without glucose monitoring and follow-up visits were the behaviors with poorest compliance.
follow-up visits as guidance, the success of an initial medication Lack of knowledge and misconception of dietary and exercise
therapy and the need for adjustment would be unclear. practices were the contributors to improper lifestyle
Regarding lifestyle self-management behaviors, our findings modification. Future interventions and strategies can be
showed that participants understood the principle of “eat less implemented according to these observed self-management
and walk more.” However, they ignored the dietary guidance and behaviors and their key influencing factors.
instead relied on preferences or dislikes of particular foods. In
particular, patients were most interested in coarse grains.
Incomplete understanding of appropriate diet choices is one DATA AVAILABILITY STATEMENT
prominent factor contributing to symptoms of poor disease
control (including hypoglycemia). In our study, the porridge with The raw data supporting the conclusions of this article will be
barley was not a good choice for patients, because porridge with made available by the authors, without undue reservation.
barley, despite containing healthy grains, is one type of food with a
high glycemic index. Such dietary misconceptions have been
demonstrated in previous studies; for example, patients with
ETHICS STATEMENT
diabetes have perceived a prohibition on carbohydrates (33, 34).
Lack of exercise knowledge was another theme for The studies involving human participants were reviewed and
noncompliance. The misconception that “Walking was the only approved by the First Affiliated Hospital of Shihezi University
way for exercise behavior” was frequently mentioned, especially Medical School (kj2020-087-03). Written informed consent for
by elderly patients. However, alternative types of exercise and
important indicators, such as frequency, timing, and intensity of
1
activities and consumption of calories, were rarely mentioned. https://www.diabetes.org/diabetes/complications/skin-complications

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Peng et al. Self-Management of Diabetes Patients

participation was not required for this study in accordance with with chronic diseases based on best-worst scaling and latent class
the national legislation and the institutional requirements. analysis” (Grant Number: 72004066).

AUTHOR CONTRIBUTIONS
DW and XP helped design the study. XP and XG performed the ACKNOWLEDGMENTS
data collection and initial analyses and drafted the initial
Thanks for the support from The First Affiliated Hospital of
manuscript. XP, HL, and YD helped design the study, reviewed
Shihezi University Medical School, Shihezi University.
and revised the manuscript. DW, XP and CL helped
reviewed and revised the manuscript. All authors contributed
to the article and approved the submitted version.

SUPPLEMENTARY MATERIAL
FUNDING
The Supplementary Material for this article can be found online at:
This study was supported by The National Natural Science Fund https://www.frontiersin.org/articles/10.3389/fendo.2022.771293/
Program “Communication preference and patterns with patients full#supplementary-material

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