Student: Mary McLeod
Supervisors: Dr Claire Dowson and Lorraine Young [Dept Public Health & General Practice and Pegasus Health]
Sponsor: Pegasus Health
Diabetes is a common condition in which there is too much glucose (sugar) in the blood. There are many complications that can arise as a result of this, however most of these can be prevented if the diabetes is well managed. The goal of this management is to keep the blood glucose levels within the normal range. A key factor in successful diabetic control is effective self-management by the patient themselves, and self-monitoring of blood glucose may have a role in this.
For Type 2 Diabetes there is no firm agreement either in the literature or amongst diabetes health professionals about the role and value of self-monitoring. There are suggestions that self-monitoring can be painful but can also impact psychologically on the patient if the blood glucose results are not within the target range.
It is estimated that around 115,000 people in New Zealand currently have Type 2 Diabetes1, and this number is continuing to increase. Due to this large number of people affected by Type 2 Diabetes, there is a high level of interest in establishing the value and importance of self-monitoring of blood glucose (SMBG) for these individuals.
The aim of the study is to consider both patients’ and clinicians’ perceptions about the value of self-monitoring of blood glucose levels in patients with type 2 diabetes.
Ten Pegasus Health General Practices volunteered to participate in the study. Six patients with Type 2 Diabetes, who are currently advised to be self-monitoring were identified and contacted by their Practice Nurse. Semi-structured, in depth interviews were conducted with these patients and also with a Health professional involved in their care. Additionally, a focus group involving eight Practice Nurses was held to explore the current professional views about the value of SMBG in Type 2 Diabetes. The interviews and focus group where transcribed and thematically analysed to identify any themes surrounding the opinions, beliefs and behaviours relating to SMBG in Type 2 Diabetes.
The six participants came from a variety of backgrounds and provided a vast range of experience and opinions. There were three females and three males whose ages ranged from 40 – 88 and the group included people who identify with Maori, Samoan and Fijian ethnicities. The participants ranged from newly diagnosed (6months) to having had diabetes for 28 years. Half of the participants are taking Insulin and the other half are taking Oral medications (2 Metformin, 1 Sulphonylurea).
The Health professionals interviewed included Practice Nurses, GPs and a Diabetes Nurse Specialist. The Nurses are mainly involved in educating the patient about Diabetes management and all aspects of self-monitoring. The GPs prescribe medications, give advice and monitor how well the patient is managing their Diabetes.
The majority of participants and health professionals perceived SMBG to be an important aspect of diabetes management. Some felt that it improved their overall diabetes management “because that’s when I know if I’m doing ok or I’m not” “so we know what’s going on and we don’t have to just rely on the HbA1cs. We can fine-tune it better”. Whereas others “think it is useful for a purpose but not generally”, “I think it assists, but it is just a small part of the puzzle”. These purposes included patients who are newly diagnosed, to monitor medications changes, “if their HbA1c is high and we don’t know why”, “to manage unwellness” and to “see what they are doing wrong with their exercise and what they are eating”. One Health professional “can’t see any advantage in self-monitoring unless the patient is on insulin”.
The participants gave a number of reasons why they were self-monitoring. Some felt it was a good way to gain control of and improve their health. One participant said “I believe that its better to do it yourself and that way it keeps you aware of what goes into your system, how much goes into your system and how to regulate your food intake” and another said “It makes you feel as if you’re in control of it.” In general the health professionals agreed that SMBG is a good “motivational tool” which provides a constant “reminder that they have diabetes” and “some people just need it to stay on track”. In contrast to this, some of the participants only monitor “because the doctor wants me to.”
Some difficulties surrounding SMBG where also identified. Common themes included “It takes up time” however “the difficulty is more remembering”. One participant found it hard to concord with the regime and she only felt comfortable to test while she was at home. “I don’t like taking it to work. I don’t like everybody knowing my business… there is a perception, you get a label… I’m just really anti having labels” and she preferred to focus on “wellness rather than illness.” The Health professionals perceived the disadvantages of SMBG to be discomfort; “pricking your finger 4 times a day is not fun”, and anxiety caused by results that are outside the target range. Another concern was that patients often focus on the values they get from SMBG and forget about the bigger picture in managing their diabetes. One nurse felt it was more important to “positively enforce the actual motivation she’s had to provide the data more so than the value, although the value to me is always in the background”. Cost was also identified as an issue. Some patients are unable to test as much as they or the Health professional would like because they are unable to afford the equipment unless it is funded.
Cultural differences can also act as a barrier, for example difficulties in communicating. One participant found it difficult to verbalise her feelings due to lack of confidence in her communication skills. The Health professionals also identified language as a barrier to education and felt “reluctant to give out anything written in another language when I don’t actually know what it means” and felt “more comfortable directing patients towards someone who can talk to them in their own language”. Diet preferences across different cultures also complicate understanding and education.
Self-monitoring is considered valuable in the management of diabetes and is useful in a variety of circumstances. SMBG is of most value when the regime is designed specifically for the patient and finds a balance between what the patient is able to manage and what is required for control and management of their diabetes.