Self-management Experiences Among Men and Women With Type 2 Diabetes Mellitus

A Qualitative Analysis

Rebecca Mathew; Enza Gucciardi; Margaret De Melo; Paula Barata

Disclosures

BMC Fam Pract. 2012;13(122) 

In This Article

Discussion

The focus of this study was to explore diabetes self-management experiences, specifically needs, challenges and barriers between men and women with T2DM. A salient finding was the difference between how men and women identify themselves as a person with diabetes or disclose their diagnosis to others. Women's public life tends to run parallel to their private one; they disclose their diabetes more readily to others and overtly practice their nutrition self-care behaviors regardless of social context. Men, on the other hand, are much more private in their disclosure of diabetes and tend to be less observant of nutrition recommendations in social settings, where changes in diet patterns could potentially make their diagnosis public. According to Charmaz, men may strive to maintain their public, pre-diagnosis identity while adjusting their private identity to their illness.[28] Concealing their illness may help preserve traditional male values such as independence, autonomy, and ownership over decision-making. Liburd and colleagues examined the influence of perceived masculinity on diabetes self-management activities among African American men and suggested that a man's desire to conform to the traditional masculine characteristics of autonomy, dominance, and stoicism may hinder self-care, glycemic control, and observance of treatment.[29] One's private versus public identity may also influence their use of diabetes resources. For instance, men turn to books and the internet for further education over more socially interactive resources, such as counseling classes and support groups which are used more by women.[30]

In contrast, women tend to disclose their diabetes more often to those in their social surroundings. Because traditional male characteristics do not apply to women, they may not view diabetes as negatively altering their identity. For example, the women in a study by Cagle et al. emphasized that they were not diabetic African American women, but rather, African American women with diabetes [.[31] This reflects an important attitude shift in chronic illness management in that individuals are separate from their diseases, not defined by them. Asbring examined the impact of chronic illness on gender identity among women with either chronic fatigue syndrome or fibromyalgia and found that women often experience early identity loss but later recognize the personal benefits to be gained from their condition, including greater insight into their lives.[32] Similarly, Koch et al. reported that many of their male participants believed diabetes changed them for the better because the diagnosis encouraged them to make positive lifestyle changes.[33] Although men may grapple with the threat of disclosing their diabetes to their public identity, they may also experience an identity trajectory of initial loss followed by a reframing process that involves separating the illness from the self. If men perceive diabetes as a threat to their masculine identity, healthcare providers may need to recognize this stigma and create an environment that initially addresses and works to dispel potential male stereotypes. In turn, men can be empowered to engage in social activities for the purpose of making healthier lifestyle choices and transition to making these lifestyle changes across varying social situations. Healthcare professionals can play a pivotal role in the transformation of self-identity following diagnosis by discouraging the labeling of people by diagnosis and introducing the illness as merely one aspect of their health that requires specific attention and management ('individuals with diabetes' versus 'diabetics').

The nature of familial support among participants in this study differed between men and women. Men identified their partners as their predominant source of social support and explained that their families contributed by adopting similar lifestyle changes, such as diet modifications. Liburd et al. also emphasized the role that wives play in men's self-management of their diabetes, particularly regarding diet.[29] However, women described less spousal support but a wider network of support. Antonucci and Akiyama also found that among patients with diabetes women have larger support networks that include siblings and children while men rely predominantly on their spouses.[34] If men view their diabetes as a threat to their masculine identity, then their use of spousal and immediate family member support reduces the number of people aware of their disease and subsequently maintains their pre-diagnosis public identity. Women's use of much larger social support networks aligns with their overt disclosure of disease and integration of diabetes into daily life. By utilizing a wide range of both formal and informal social supports, women may more easily make healthier lifestyle choices, regardless of social setting. Both men and women made use of social support available from immediate family members; however, women received encouragement or reminders of what not to eat or scrutiny over the amount eaten, whereas men's household environment changed to support nutrition recommendations. Based on previous studies and our results, women appear to rely on a wider net of social support. As such, healthcare professionals should encourage the participation of family members, as well as other members of a person's social network, in diabetes self-management education. In this way, educators help women build positive and well-informed support networks.

Based on the transcripts, it is clear that both men and women recognize the value of SMBG, link their physical symptoms to variations in glucose levels, and make appropriate behavioral adjustments. Men and women, however, vary in their concerns about SMBG; specifically, women focus on their fears and anxieties whereas men focus on the technical aspects of SMBG.[35] Our results support a similar finding that report men value the technical understanding of blood glucose control.[33] In spite of recommendations made by physicians and diabetes educators, men in our study were more proactive in experimenting with both SMBG and multiple aspects of diabetes self-management. The fact that both men, and to some degree women, experimented with self-care to some degree may indicate inquisitiveness and desire to learn from experience. Our results highlight the importance of not only adopting a patient-centered approach to diabetes care and counseling by addressing the salient issues that are identified by the patients themselves but also being knowledgeable and sensitive to particular gender interests such as calibration of glucose monitoring devices with men and fears and anxieties associated with SMBG among women. Healthcare professionals may find it helpful to share the common interests, fears and anxieties that men and women have with individuals who may be reluctant to ask questions or resistance to learning a new self-management skills such as SMBG or insulin administration.

Another important finding in our study was the notion among women that certain foods were forbidden rather than permitted in moderation, which might be the result of gender-specific attitudes held by women. Women in our study made repeated comments about missing or mourning certain foods; the perception that specific foods are forbidden may account for a mourning period that some women experience, during which time they adjust to complete abstinence from previously favorite or culturally preferred foods. Men, on the other hand, did not discuss mourning of foods; they appeared to focus on moderation of foods rather than restriction of any given food. However, men did discuss difficulties with adherence to dietary recommendations in social settings; these findings suggest that men too may also benefit from nutritional counseling with a focus on safe and effective strategies to integrate nutrition self-management skills during more challenging situations, or when away from home. These knowledge gaps might be the result of several factors including pre-conceived notions about food consumption, pre-occupation with restriction rather than moderation of foods perceived as unhealthy or conflicting information from multiple sources. According to research, women hold the misconception that nutrition therapy for weight loss requires over-restricting caloric intake and complete elimination of specific foods.[36] Therefore, if past dietary choices were guided by over-restriction, similar stringent eating patterns may continue after diagnosis. Dixey discusses women's complex relationship with food, suggesting that although they are primarily responsible for the family's food, they feel compelled to deny themselves certain foods in order to live up to the gender stereotype of slimness.[36] Polivy reports that food restriction can cause various cognitive disruptions, predisposing those who restrict intake to eat excessively - even binge - once restrictions are lifted; these behaviors can cause them to become overly preoccupied with and emotionally responsive to food.[37] Given the importance of nutrition self-care in diabetes self-management, healthcare providers should specifically assess individuals, in particularly women with diabetes, about food restriction, moderation and portion size. Based on our results, which demonstrate that women predominantly focus self-management on nutrition and dietary recommendations, guidance and education about nutrition self-management may be a more pertinent self-care strategy for women. Healthcare professionals may find that initiating counseling by addressing nutrition self-management interests may be an effective starting point for building rapport and trust with women. Empowering women to adopt a balanced approach to healthy eating might be more successfully obtained by providing counseling on inclusion of favorite foods and debunking food myths and misconceptions.

Limitations

There are several important limitations that should be taken into account. The study population was pulled from a large, urban, culturally diverse city in Canada. As such, findings may not be representative of other and more culturally homogeneous populations of people with diabetes. Furthermore, we have limited information about the characteristics and time spent in the North American healthcare system of foreign-born participants and the amount of potential assimilation to western role expectations – this might act to potentially confound our results. We did not collect specific information regarding the ethnic and cultural background of those patients who reported being foreign-born, nor did we identify which cultural background participants identified with most strongly. Given the wide variations in cultural norms regarding diet, physical activity, and masculine and feminine gender roles and norms influencing health behaviors, the role of culture should be further investigated in future studies. The same interview guide was used for the focus groups and the individual interviews. There are potential differences that might occur due to this sampling strategy but using different methods can be potentially be a strength: for example, participants might mention more private self-care issues that might not come up in a focus group. While this mixed sampling methodology may be a limitation, we felt that it was more important to interview more participants than to include only those who were able to attend focus group. Finally, this study was based on secondary data and participants were recruited based on the degree of diabetes education participation at the DEC. For instance, approximately half of the participants had accessed the full range of diabetes education programming at the DEC, and others did not return for follow up after their initial visit. Therefore, our findings should be interpreted within the context of secondary data analysis.

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