FINDINGS
Organizational level
Participants identified several factors that shed light on how they perceive organizational resources and support they get for self-management.
Most patients reflected positive feelings towards attending the clinic expressing feelings such as eagerness, motivation and excitement. There was however also some negative feelings mentioned such as that of inconvenience. These were mostly brought on by long waiting times. Although some respondents said that they have resigned themselves to waiting, others expressed feelings of frustration
P3: Yah I come here in the morning, go for my blood tests, go to get my folder, there it’s a hell of a wait, and I think that brings your sugar and your blood and everything up…..
Generally the feelings of patients after leaving the clinic were positive. They felt satisfied or happy. When expressing overall satisfaction with the care received at the clinic, comparisons were made to other institutions visited previously and the poor service they received there.
The majority of patients were satisfied by the check-up received from their doctor. Those that were satisfied similarly expressed a good relationship with their doctor, as well as some indicating that their doctor acted as a form of support system in the management of their condition.
On the other hand those that were dissatisfied with their check-up indicated poor patient- provider relations. One patient for example complained about the appearance of the doctors, comparing them to “hippies” and saying
P6: They look so playful; they don’t look like the doctors with the white coats of that years you know.
A theme that emerged from discussions was that all the patients had been seen by different doctor,
half of the patients found this to be problematic and preferred to be seen by one doctor.
The majority of patients indicated that they had no problems with the others staff members at the clinic, referring to the nurses in particular. However, only a few found them to be friendly and helpful. At the same time they reported having issues with some staff members being strict and not attentive and not understanding them.
P1: You give me this stuff, I can’t eat it. They don’t understand. Because the nurses give me a lot of things I can’t eat, they don’t understand. They strict, you must eat this. I don’t like it.
Many patients were satisfied with the service provided by the dieticians. They generally felt that they were experts in their field and provided them with information that was helpful, good and interesting.
P8: Very good in the sense that they tell you what you can buy and what you cannot buy, and you don’t waste your time now in the supermarket. You know, it’s so invaluable, you know where research is being done and they can tell you exactly, cause you don’t know if your sugar is going to spike if you going to eat it, or if it’s going to stay stable you know what I mean.
However there were a few exceptions to this. One patient did not want to see the dietitian, due to her age and religion, she did not feel that the dietitian would be able to change her diet and that it was not necessary since her glucose was well controlled.
P1: I don’t want to see a dietician, because I don’t eat the stuff they give me. Because why being a Muslim, and because at my age, I don’t think I will be able to change my diet. I think my diet is fine. The doctor showed me on the computer now since 2009 my sugar has been so good, very well, even this morning.
Community level
Inappropriate cultural food availability
With the majority of the patients Muslim and of mixed ancestry, the cultural barriers were very specific. The strongest theme mentioned were that of a preference for traditional foods.
Other cultural factors revolved around social events, celebrations, and religious practices.
Ramadan (Fasting) was mentioned quite a few times in the interviews. This was found to be a barrier due to the presence of particular “forbidden” foods being more present.
P7: And you know next month also is another month in our lives, where all those things are on the table.
A similar notion was found with regards to social events, such as weddings, birthdays, Eid celebrations, and funerals as being a barrier in terms of making it difficult to adhere to dietary guidelines
P9: Oh I try, But my sugar does go hey wire, you go to a wedding, ahhh and you eat all those things, the sorghi, and the vermicelli, and the samoosas, and the pie, and especially if you hungry, and your sugar is twenty, and you already cockeyed, and you just want to sleep.
Food insecurity
Half of the patients had brought up their economic status as a factor that makes it difficult to adhere to the dietary guidelines.
P3: You know but as money goes lower with the month, your diet also drops…. And then you just lapse.
Other community and policy factors mentioned that affected attendance at the clinic were in relation to transport, traffic issues and work commitments.
Family small group level
The majority of patients reported that they do receive support from their families, albeit some in the form of admonishment.
P5: My son, I’m living with him, his always care and support. Mummy do this, mummy be careful.
Half of the patients indicating that they received family support also similarly indicated their lack of support in certain aspects especially as in this case with regards to meal preparation.
Issues raised were that of the inconvenience of cooking separate meals for the patients with diabetes.
P3: To me it’s my wife’s job, you know and by the time I get home I forgot about whatever I was told, or whatever. You know even the wife for that matter, she listen to you now, for that week you gonna eat healthy, you not gonna eat anything that you really want to eat, because she wants to give you healthy food. And after that you know, then you just eat what they eat, because they ‘dik’ of giving you special food. You know then they go back to, ‘Ja man, ek het nie nou tyd nie’. And you go back to you know, tomorrow we start again, and then it fades, and you just take what you get
Individual level
Although patients mostly reported adherence to the diabetic dietary guidelines analysis of the data show many instances of poor dietary practices.
P1: I only use canola, but only a little bit. I use only canola margarine, not the hard one, that’s the bad one, and then later in the interview, I will first ask my sisters, is the pies ok?
Not to fatty not to oily, no? Then I will eat it.
Analysis and interpretation of the interview data revealed the following barriers and enablers that participants experienced on several different levels of influence in trying to adhere to recommended nutrition guidelines
Most participants indicated that they think that it is ultimately the responsibility of the individual to follow the dietary guidelines given to them.
(P3) : It’s just always up to the person himself. They can give you as much information, and give you literature, a second survival note; you know it’s up to you as a person. I mean they can just do what they can do, and what they supposed to do, more than that they can’t do.
They can’t force you.
Most participants refer to the preference for specific foods especially high fat and sugar containing foods. The craving for these foods often served as a barrier to adhering to nutrition guidelines
P3: You know I had a gas cold drink with sugar, you know I know that it is a wrong, it’s just the craving you know, somebody else drinks it, and you also want. I don’t drink like sugar free stuff and I think it’s by time now I get myself use to it.
P7: I say yes, I’m just going to eat a small piece man, I must taste, it taste ok, ok right I will leave it. I said to them now we are not by the eating department, we are by the tasting
department; you know what I’m saying. If you taste the koeksister taste nice, you cannot eat five, you can only eat one, you understand what I’m saying?
The majority of participants mentioned motivating factors that influence their adherence to nutrition care guidelines. This motivation varied amongst patients, and ranged from; fear of death, their relations with others and achieving a goal/result.
P5: I think it will be different from now on, before I didn’t care, I just had this thing that uuh, you got to go, you got to go, whether it’s with sugar or not sugar. And uhmm, all people try is to give you a better life, to make your life better, but if you have to go you have to go, whether you take insulin, or not insulin, or whether you take tablets of not, you got to die you got to die.
A notion of the ‘death concept’’ emerged as a common theme to motivation which could be seen as an enabler or barrier to adherence. Fear of death or adopting the complications of the disease, in particular to amputations was apparent amongst half of the subjects, this fear acted as an enabler to adherence. Some patients felt that death was inevitable, therefore they were going to die irrespective of whether or not they had adhered to nutrition care guidelines. Two of the patients had shown will power and determination to drive their actions. In the above cases it was derived from the religious believes or strict upbringing.
When patients were asked to recall what nutrition information they had received from the clinic, references were made to particular aspects of the diet in relation to one or more nutrients. These reports by the respondents reflected some understanding. The understanding of the definition of what diabetes was poor and only 1 participant understood what diabetes was. Those that had some understanding showed confusion in other respects such as the misinterpretation of the relation between glucose and insulin in the body.
P3:Yah diabetes is to do with your glucose levels, insulin levels at least, and uhmm there’s too much glucose in your body that eats up insulin, right and that’s why you need to get artificial insulin in you, because your pancreas doesn’t function 100%. So the medication they give you is to help your pancreas manage your insulin levels.
