DIABETICMedicine

DOI: 10.1111/dme.12105

Review Article
Barriers to self-management of diabetes

A. J. Ahola1,2 and P.-H. Groop1,2,3

1
Folkh€
alsan Institute of Genetics, Folkh€alsan Research Center, Biomedicum Helsinki, 2Department of Medicine, Division of Nephrology, Helsinki University Central
Hospital, Helsinki, Finland and 3Baker IDI Heart and Diabetes Institute, Melbourne, Vic., Australia

Accepted 18 December 2012

Abstract
People with diabetes hold major responsibility for the day-to-day management of their chronic condition. The management
that, amongst others, includes blood glucose monitoring, medication taking, diet and physical activity, aims at normalizing
blood glucose levels. In many individuals, the level of glycaemia, however, frequently exceeds the recommendations.
This observation, together with patients’ and practitioners’ reports, suggests that active self-management is suboptimal.
Various reasons, both individual and environment related, contribute to the suboptimal concordance with treatment
regimen. The aim of this review is to discuss some of the barriers to optimal diabetes self-management.
Diabet. Med. 30, 413–420 (2013)

good self-management. In order to promote concordance

Introduction
Self-management of diabetes aims at normalizing blood
glucose content and reducing the risks of long-term compli-
cations. Ideally, the rationale, implementation and goals of
the self-management are formulated in close collaboration
between the person with diabetes and the healthcare team.
Concordance with the jointly agreed regimen, characterized
by the individual’s active and responsible role, is considered a
prerequisite for the successful management of diabetes.
Despite the known benefits of prudent adherence to the
treatment regimen, suboptimal levels of glycaemic control
are frequently observed [1].
The observed difficulty in achieving good glycaemic
control suggests that concordance with the diabetes regimen
is inadequate. In our own study, for example, 64% of the
individuals with Type 1 diabetes were observed to be hypo-
or hyperglycaemic postprandially, indicating that for one
reason or another the majority of study participants did not
reach normoglycaemia approximately 2 h after a meal [2]. In
another study, only 46% and 39% of the individuals with
Type 1 and Type 2 diabetes, respectively, achieved ‘complete
success’ in at least two-thirds of their self-management
domains for which they reported having received recommen-
dations [3]. Independent of the diabetes type or its treatment
mode, the most frequently encountered barriers are related to
diet and physical activity [4,5], while concordance with the
medication regimen is typically higher [5,6].
Self-management is associated with various individual and
environment-related factors that either promote or impede
Correspondence to: Per-Henrik Groop. E-mail: per-henrik.groop@helsinki.fi
with the treatment regimen and improve glycaemic control, it
is important to acknowledge and address any such barriers
collaboratively. This review aims at describing some of the
observed barriers to the concordance with self-care regimen
in diabetes.
Knowledge, empowerment and health
literacy
In order to appropriately manage one’s diabetes, knowledge
about the self-care procedures is imperative. Lack of knowl-
edge ranks high in studies investigating barriers to self-
management [7] and inadequate understanding of the
recommendations increases the likelihood of non-adherence
[8]. Knowledge of diabetes care has been associated with
activities such as medication taking, diet, exercise, blood
glucose monitoring and foot care [9]. In this respect, elderly
people with Type 2 diabetes may be especially vulnerable, as
previous studies have demonstrated serious deficiencies in the
diabetes knowledge, not only in these individuals but also
their relatives [10,11]. Moreover, increasing frequency of
memory problems with advancing age set, in particular,
challenges to education. Importantly, individuals with
diabetes have reported that they need more information
about issues which clinicians may consider rudimentary, such
as the diagnosis itself, the rationale for blood glucose
monitoring, and how diabetes-related risks may be reduced
[12]. Assimilation of information may be particularly
attenuated at the time of the diagnosis. Therefore, repeating
later the information given during the initial counselling may
be beneficial for the affected individual.

ª 2012 The Authors.

Diabetic Medicine ª 2012 Diabetes UK 413
DIABETICMedicine
Table 1 Potential issues associated with good management of diabetes
Individual related
Knowledge
Empowerment
Health literacy
Motivation
Health beliefs
Self-efficacy
Coping and problem-solving skills
Locus of control
Depression
Anxiety
Forgetting
Excess use of alcohol
Other diseases that may interfere with diabetes management
Environment related
Social support
Provider factors
Socio-economic factors
Distance to the site of health care
Other competing interests and duties
Factors related to the availability of good quality health care,
nutritious foods, exercise opportunities, etc.
Various interventions, with variable levels of success, have
been undertaken to either increase the diabetes knowledge or
provide skills to improve self-management. A meta-analysis
of such studies showed that, at least in the short term, the
knowledge levels, self-monitoring practices and dietary
habits tend to improve [13]. However, increased knowledge
is not consistently related to glycaemic control. In particular,
didactic interventions without interaction between partici-
pant and instructor proved less efficient in improving
glycaemia compared with interventions more collaborative
in nature [13]. The Dose Adjustment for Normal Eating
(DAFNE) is an example of a comprehensive educational
programme aimed at improving diabetes management in
Type 1 diabetes. The programme emphasizes the importance
of insulin dosing in relation to the carbohydrate content of
the meal. Importantly, individuals completing the pro-
gramme have shown reduced levels of glycaemia. According
to the programme participants, increased knowledge was one
of the factors affecting their ability to better control diabetes
after training [14]. For people with Type 2 diabetes, a similar
group education programme called DESMOND (Diabetes
Education and Self-Management for Ongoing and Newly
Diagnosed) has been designed [15]. Most of the curriculum
of the programme is focused on lifestyle factors, such as
dietary choices, physical activity and cardiovascular risk
factors. Importantly, there is currently a lack of structured
education for minority groups.
While knowledge is unquestionably important in self-care,
it alone is unlikely to be sufficient to improve diabetes
control. It can be speculated that, while the less knowledge-
able individuals may be prone to passively follow the
instructions and consequently achieve good glycaemic con-
trol, those with more knowledge may be more flexible in
their self-care behaviours and fail to reach the HbA1c goals.
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Barriers to self-management of diabetes  A. J. Ahola and P.-H. Groop
Although knowledge does not thus guarantee good glycaemic
control, it can help some people feel empowered to actively
participate in decision making regarding their self-care.
Importantly, those with lower levels of knowledge may be
overwhelmed by the information overload, currently avail-
able from various sources, and be paralysed to make any
treatment decisions oneself. Knowledge, together with suffi-
cient resources such as skills, contributes to empowerment; it
gives the individuals freedom to make choices between
different treatment options. Empowerment was indeed
another factor identified by the DAFNE participants to
influence their ability to keep in control with their diabetes
[14]. The shift from a rigid adherence to provided instruc-
tions to making informed choices that better suit individual
life circumstances was liberating for many of the partici-
pants. Feeling empowered to self-manage one’s diabetes is
associated not only with better concordance with self-care
behaviours, but also with increased quality of life and better
treatment satisfaction [16].
Health literacy, a term closely related to knowledge, refers
to the individual’s capacity to read, understand and make use
of healthcare-related information for decision making and
self-care. In diabetes, health literacy is required for tasks such
as understanding the rationale behind the self-management
regimen, reading and interpreting food labels, carbohydrate
counting and appropriate insulin administration. While low
levels of health literacy may not prevent blood glucose
monitoring, to interpret and correctly act upon the obtained
results may be compromised in low health literacy. Subopti-
mal health literacy is also related to reduced ability to recall
oral medical instructions and the consequences of worse
glycaemic control [17,18]. Interestingly, various services,
education programmes and interactive diabetes management
sites have recently become available via the Internet. Thus,
health literacy is increasingly being linked to computer
literacy, which may disadvantage certain patient groups, such
as elderly individuals. Despite these observations, conclusions
made in a recent review paper do not support the intuitive
expectation that low health literacy would automatically be
associated with inadequate diabetes self-management [19].
Instead, health literacy might influence self-management via
sociocognitive variables such as motivation.
Motivating self-management—health
beliefs
Despite a sufficient amount of knowledge and a fairly good
perception of one’s abilities to make changes, adopting and
maintaining self-management practices may not always be
easy. Indeed, motivation is a major factor in self-manage-
ment. The importance of motivation was also identified by
the DAFNE participants as a factor influencing their self-
management [14]. Motivation may be extrinsic, such as
the type of motivation provided by the healthcare team.
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Diabetic Medicine ª 2012 Diabetes UK
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However, it is the intrinsic motivation that seems more
important in active self-management. In particular, finding
motivation for behaviours with consequences not immedi-
ately apparent, such as healthy eating, can be difficult.
Additionally, motivation is likely to be affected by goals.
While for some individuals good glycaemic control is an
important means to increase longevity and better physical
functioning, others may value the freedom from the daily
diabetes burden as more desirable and thus choose not to
meticulously focus on the diabetes self-management.
Individuals hold various intrinsic health beliefs that directly
influence their attitudes towards health and health-related
behaviours, influencing their motivation to act. There are
clear differences between the viewpoints of practitioners and
those of people with diabetes. Many practitioners would, for
example, find a person with a BMI of 31 kg/m2, waist
circumference 103 cm, blood pressure 152/85 and HbA1c
69 mmol/mol (8.42%) at a fairly substantial risk of develop-
ing long-term complications. However, in one study, partic-
ipants with Type 2 diabetes with these mean values were not
markedly worried about the consequences to their future well-
being [20]. Indeed, although people are aware of various
health risks, the degree to which they perceive these risks as a
concern to them personally may differ. The majority of
insulin-treated individuals in one study, for example, believed
that, although complications related to diabetes were severe,
their own susceptibility was not particularly likely [21].
In addition to the perceived susceptibility, as addressed in
the Health Belief Model [22], individuals make a number of
other judgements related to health risks and health behav-
iours. According to the model, individuals assess not only
the severity of the condition and its potential consequences,
but also barriers and benefits associated with the behav-
iours. Thus, prior to adopting a health behaviour, it is
important to work collaboratively to determine the per-
ceived severity of the condition, alongside the benefits and
barriers of engaging in such a behaviour change. Addition-
ally, according to the Health Belief Model, various cues to
action are thought to modify behaviour through perceived
threat of the condition. Such cues may be internal, such as
various symptoms, or external including advice from the
healthcare personnel.
Of the dimensions in the Health Belief Model, perceived
barriers best explain health behaviours, while perceived
susceptibility explains preventive self-care behaviours, and
perceived benefits and perceived severity explain sick-role
behaviour [23]. In a study conducted among individuals
with Type 1 diabetes, higher perceived benefits in relation
to costs predicted adherence to diet and blood glucose
monitoring [24]. However, perceived threat related to
diabetes and its complications did not motivate self-care
behaviours. Of the cues to action, social support was
related to dietary adherence, while perceived metabolic
control and hypoglycaemic symptoms were related to blood
glucose monitoring.
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Diabetic Medicine ª 2012 Diabetes UK
DIABETICMedicine
From self-efficacy to the theory of planned
behaviour
Self-efficacy refers to an individual’s belief in one’s compe-
tence in successfully performing a given action. An individual
with solid confidence in one’s abilities is not only more likely
to initiate behaviours, but will also, in the case of an
unforeseen obstacle, be more persistent in one’s attempts
compared with a less confident counterpart.
Higher self-efficacy is associated with more prudent self-
care behaviours [25,26] and better glycaemic control [27],
indicating that individuals who perceive themselves more
confident in managing their disease are also more likely to do
so. ‘Diabetes management’ is not a single unit, however, but
consists of a number of individual tasks, of which some may
be easier to tackle than others. Of the self-care procedures,
people with diabetes seem most confident in their abilities to
perform medication-related tasks [26]. While individuals are
also self-efficient in blood glucose regulation, substantially
lower efficacy rates are observed for physical exercise and
dietary intake. In line with these observations, people with
diabetes have reported higher frequencies for medication-
taking (5.6 times) and blood glucose monitoring (4.7 times)
over the previous week, compared with behaviours such as
following the recommended diet (3.5 times) and physical
activity (2.7 times) [28].
The theory of planned behaviour takes one step further in
trying to explain such a complex behaviour as self-care [29].
According to the theory, behaviours are best predicted by
behavioural intentions. These intentions are influenced by the
individual’s attitudes towards the behaviour, perceived
subjective norms and perceived behavioural control. Atti-
tudes towards the behaviour refer to the individual’s own
assessment of the act or its consequences. Subjective norms
are the individual’s perceptions of the social normative
pressure regarding the act, and perceived behavioural control
refers to the individual’s perceptions regarding one’s abilities
to perform the task.
In a study among people with Type 2 diabetes, attitudes,
subjective norms and perceived behavioural control explained
49% of the variance in the intent to carry out self-care
behaviour, while perceived behavioural control explained
most of the variance in the actual behaviour [30]. White et al.
investigated whether attitudes, norms and perceived control
were related to physical activity and consumption of foods
low in saturated fatty acids [31]. With respect to the physical
activity level, differences were observed in attitudes and
perceived control. Compared with the less active, those highly
active were more likely to think that exercising makes them
feel healthy and less likely to anticipate that exercise would
make them feel sore afterwards. Moreover, those less active
more likely reported that laziness prevented them from being
physically active. Regarding dietary intake, differences were
observed in attitudes and norms. Those highly adherent to the
low saturated fatty acid diet were more likely to perceive that
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such a diet makes them feel healthy and less likely to
anticipate that the diet requires use of unfamiliar ingredients.
However, those not adhering to the diet more frequently
expressed a view that their important referents (families,
friends and peers) would not approve of such a diet.
Coping and problem-solving skills
Coping refers to an individual’s responses to encountered
challenges and their ability to solve problems in order to
manage stress [32]. Coping involves all spheres of human
existence, i.e. cognitions, affects and behaviours. Depending
on areas emphasized, division into appraisal-, emotion- and
task-focused coping strategies may be carried out. In
appraisal-focused coping, individual aims at changing one’s
cognitions related to the problem. This may be accom-
plished, for example, by distancing oneself from the problem
or denying its existence or significance. The use of emotion-
focused coping aims at managing the emotions aroused when
facing the problem. Finally, when employing task-focused
coping, the individual, via selected actions, aims at eliminat-
ing or reducing the effect of the problem.
Denial, as a coping mechanism, is a key factor inhibiting
adherence to a healthy lifestyle [12]. In insulin-treated
individuals, denial is associated with worse glycaemic control
[33], while task-oriented coping is likely to improve it.
Individuals using wish-fulfilment coping, however, have been
shown to be less healthy than those using problem-solving
coping strategies [34]. Coping strategies should be discussed
collaboratively to facilitate potential barriers and ensure
appropriate goal setting.
Prior to successfully tackling a given problem, it has first to
be acknowledged. Indeed, only after having identified the
problem, one may specify the desired goals and any potential
barriers related to the required behaviour. This is followed
by selection and implementation of appropriate actions and,
subsequently, evaluation of the outcome. The chain of events
taking place after having acknowledged the problem is called
problem solving. As the responsibility of the diabetes
management rests heavily on the person with diabetes, its
success depends on the individuals’ ability to adequately
solve various problems on a day-to-day basis.
The importance of problem solving has been shown in
various studies. King et al., for example, reported that
problem-solving ability was associated with healthier eating
patterns [25]. In another study, better executive functions,
referring to planning and problem-solving abilities, indepen-
dently predicted better diabetes self-management [35]. Those
with better problem-solving skills also monitor their blood
glucose levels more frequently [36].
Locus of control
Individuals possess different views regarding how much they
have personal control over the events occurring in their lives.
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Barriers to self-management of diabetes  A. J. Ahola and P.-H. Groop
Those assuming that occurrences are a result of their own
behaviours are thought to have an internal locus of control,
as opposed to the ones with external locus of control for
whom the causes lay within the environment, luck or chance.
The perception of control over one’s life events is undoubt-
edly also important in diabetes management, and it has also
been acknowledged by the people with diabetes themselves.
In one study, the majority of insulin-treated individuals
perceived internal control as the culprit for their diabetes
control, while the external factors were appointed to a much
lesser extent [21]. In addition, a group of people with Type 2
diabetes generally acknowledged that their diabetes control
was something they could personally influence, but also
stressed the strong impact health professionals and family
members had on their control [37]. Belief in one’s ability to
have control over life events and higher perceptions of
longevity have been associated with more prudent diabetes
self-care practices and better self-assessed diabetes control
[38].
In their study, Peyrot and Rubin separated internal
diabetes locus of control into ‘autonomy’ and ‘self-blame’
components [39]. Autonomy was found to be associated with
higher diabetes self-efficacy and emotional well-being, while
less frequent blood glucose monitoring and insulin dose
adjustment, and more frequent binge eating were associated
with self-blame. These results highlight the importance of
distinguishing between the two factors within the single
concept of internal locus of control. Although internal locus
of control is generally regarded as an empowering charac-
teristic, enabling an individual to act in order to influence
their health, a person who perceives that his or her actions
determine health is probably also more likely to blame his- or
herself in the case of negative outcomes. Importantly, as seen
in the above study, such a self-blame may negatively affect
self-care behaviours.
Potentially because of the dichotomized nature of the
concept of internal locus of control, inconsistent results have
been obtained from studies investigating its association with
glycaemic control. In one study, internal locus of control was
associated with better glucose control in insulin-treated
diabetes [33]. Yet, no association was found in a population
of 1034 individuals with diabetes [38].
Depression
Depression, commonly observed in people with diabetes,
may negatively affect how individuals take care of them-
selves. Importantly, depressed individuals do not differ in
diabetes-related knowledge from their non-depressed coun-
terparts, but it is rather the depression-related symptoms,
such as loss of interest, reduced decision-making ability and
fatigue that likely contribute to the poor self-management
[40]. Even low levels of depressive symptoms, and not only
clinical depression, have a negative impact on self-care
adherence [41]. Amongst others, depressive symptom
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Diabetic Medicine ª 2012 Diabetes UK
 Review article
severity in diabetes has been associated with a less prudent
diet and a reduced adherence to medication regimen [42].
Additionally, depression has been shown to negatively
impact blood glucose monitoring [6]. In people with Type 2
diabetes, depression, via reduced social motivation, impedes
treatment-seeking behaviour and the adoption of effective
self-management behaviour, including physical activity,
healthy diet and blood glucose monitoring [43].
Despite the established association between depression and
diabetes self-care, the relationship between depression and
glycaemic control is more controversial. A meta-analysis of
24 studies including 2817 individuals with Type 1 or Type 2
diabetes concluded that depression was associated with poor
glycaemic control [44]. However, another meta-analysis of
1540 participants failed to show such an association [45].
Moreover, some studies have shown an association between
depression and glycaemia only in individuals with Type 1
diabetes [46]. Complexity of the treatment regimen may
offer an explanation for this observation. Indeed, Surwit
et al. reported that, among individuals whose diabetes was
managed with three or more daily insulin injections, depres-
sive symptomatology was associated with HbA1c [47].
However, with a less intense diabetes management regimen,
depressive symptoms were not related to glycaemic control.
The authors concluded that the complexity of the treatment
regimen offers more opportunities for the negative mood to
impact self-care. Importantly, potential association between
depression and glycaemia does not automatically denote
causality. After all, depression may deteriorate glycaemic
control via impaired self-care practices, but poor glycaemic
control may also aggravate depressive mood.
Fear of hypoglycaemia
Hypoglycaemia, a condition where plasma glucose level falls
below 4.0 mmol/l, is a common side effect of intensive
diabetes management. The risk of hypoglycaemia is
increased in insulin-treated diabetes, but is also evident
when diabetes is managed with oral agents, particularly
sulphonylureas. Subsequently, iatrogenic hypoglycaemia is
not only common in Type 1 diabetes, but is also observed in
advanced Type 2 diabetes, especially following defective
glucose counter-regulation [48]. Besides glucose-lowering
drug therapy, factors such as strenuous physical activity,
liberal alcohol consumption and omission of carbohydrate-
containing meals contribute to hypoglycaemia. If untreated,
hypoglycaemia leads to unconsciousness, convulsions and
even death. In the case of severe hypoglycaemia, external
assistance in the form of a glucagon injection or glucose
infusion is needed to treat an unconscious individual. As the
seriousness of severe episodes calls for a certain degree of
healthy concern, the possibility of hypoglycaemia sets limits
to the glycaemic management of diabetes [48].
Because of the unpleasant symptoms, associated health
risks and its socially aversive nature, individuals with
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Diabetic Medicine ª 2012 Diabetes UK
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diabetes generally try to avoid hypoglycaemia. In practice,
total avoidance may be difficult, however, as seen in one
study where 36% of the individuals with Type 1 diabetes
reported having experienced hypoglycaemic coma during
their lifetime [49]. Severity and frequency of the episodes
contribute to the fear of hypoglycaemia. Pramming et al.
reported that individuals with Type 1 diabetes fear severe
hypoglycaemia to the same extent as they fear diabetic
complications [49]. Moreover, fear of hypoglycaemia is also
observed among persons with Type 2 diabetes [50]. Impor-
tantly, fear of hypoglycaemia may be an important barrier
for the good self-management of diabetes. In some individ-
uals, fear of hypoglycaemia may lead to the tendency to
maintain hyperglycaemia, which, again, has other long-term
consequences, such as higher rates of microvascular compli-
cations and increased risk of death [51].
Among adolescent boys with Type 1 diabetes, fear of
hypoglycaemia was independently associated with lower
adherence to the insulin regimen [52]. In addition, among
people with Type 1 diabetes, fear of hypoglycaemia can be a
major barrier to physical activity. Importantly, factors such
as knowledge of insulin action and a post-exercise evening
snack to reduce the possibility of nocturnal hypoglycaemia
are associated with reduced fear of hypoglycaemia, and may
thus increase the probability of being physically active. Of
interventions to alleviate fear of hypoglycaemia, cognitive
behaviour therapy and blood glucose awareness training
have been shown to be efficient [53]. While cognitive
behaviour training helps individuals handle their emotions
when confronting the fearful aspects of hypoglycaemia, the
blood glucose awareness training may both reduce the fear of
hypoglycaemia but also the actual frequencies of the
episodes.
Social support
Social support refers to the individual’s perception that
assistance is readily available should one need it. Provided
support may be emotional (e.g. empathy, acceptance, affec-
tion), tangible (e.g. financial support, modifying environ-
ment), informational (e.g. education, advice) and appraisal
(e.g. feedback, affirmation). Support may be obtained from a
number of sources including friends, family members and
physicians. In a study among individuals with Type 2
diabetes, the attending physician was most frequently (43%
of the respondents) identified as the primary source of
support, followed by the spouse (20%) or another family
member (19%) [28]. In the same study, however, a total of
8% of the respondents reported receiving no support at all.
Social support is not only positively associated with the
individuals’ perceived self-efficacy in conducting diabetes-
related tasks [54], but also with the actual self-management
behaviours. Specifically, positive social support is predictive
of adhering to diet, exercise, medication and blood glucose-
monitoring regimen [28]. Lack of support from one’s family
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DIABETICMedicine Barriers to self-management of diabetes  A. J. Ahola and P.-H. Groop
is an important barrier for the active self-management of
chronic conditions. This is true especially for activities, such
as eating and physical activity, which are frequently con-
ducted within social encounters. Family support is also an
extremely important factor in childhood and adolescence,
when the individual is still learning the issues related to good
self-management. In the case of Type 1 diabetes, adolescents
who perceived greater caregiver responsibility engaged in
more frequent blood glucose monitoring [55].
Although family support is frequently recognized as an
important factor in lifestyle changes, only 13% of the
respondents with diabetes reported that their families had
made any adjustments to their lifestyles that would benefit
them [4]. Moreover, while marital satisfaction has been
associated with better adaptation to insulin-treated diabetes
[56], not all support is beneficial. Female participants who
perceived their partner as overprotective benefited the least
from an intensive education programme [57]. The investiga-
tors speculated that overprotection communicates low trust
in ones’ abilities and thus negatively affects one’s diabetes
self-management.
Provider factors
The quality of provided health care may also influence how
people with diabetes take care of themselves. Poor commu-
nication with the physician, for example, may impede active
diabetes self-management. Patient-identified factors promot-
ing a good patient–provider relationship include openness to
dialogue, ability to listen attentively, providing sufficient
amount of time for a patient, providing information and
giving rationale for the treatment recommendations [8]. The
relationship with the healthcare provider is considered
important to the extent that individuals are willing to change
their healthcare providers in order to find a practitioner who
listens to their concerns and gives concise and simple
instructions [7].
In one study, the majority of the 1092 individuals with
Type 2 diabetes described their patient–provider relationship
as unilateral; that is, one in which physicians make decisions
and patients are expected to comply [4]. However, being
engaged in an active partnership, as opposed to a unilateral
relationship, was associated with a less sedentary lifestyle
and favourable changes in dietary habits. Importantly,
patients’ and healthcare professionals’ reports of the issues
discussed during the consultations may differ significantly. In
one study, of the 308 topics the professionals reported having
been discussed, patients recalled only 180 [58]. Moreover, of
the 168 professional-reported decisions made at the consul-
tations, patients reported 94. These results indicate a clear
need for improving practitioners’ communications skills in
order to improve patients’ understanding of the instructions
and subsequently their self-management.
One way of ensuring that a patient has understood the
items discussed is to ask, after the consultation, an individual
418
to restate the given information or instructions in their own
words. This enables the practitioner to clarify any misappre-
hensions at the time of the visit. Such an interactive
communication does not seem to be a norm, however [59].
Importantly, individuals whose physicians had ensured that
the message was properly conveyed were more likely to have
lower HbA1c levels compared with those whose physicians
did not.
Furthermore, healthcare personnel should be aware of the
primacy effect. That is, individuals tend to remember the first
things they are told. The use of straightforward language and
simple sentences should also be favoured. Active self-man-
agement may further be promoted by explaining why certain
self-care behaviours are important. Additionally, complex
instructions should be broken down into smaller segments
and important messages repeated to ensure they are not
missed. Also to increase adherence specific advice, instead of
general statements, should be provided. Finally, active self-
management may additionally be promoted by providing the
individual with written instructions to be used as a memory
aid.
Physicians’ knowledge, beliefs and attitudes may also
influence patients’ self-care practices. Peyrot et al. observed
that providers’ beliefs about insulin efficacy were associated
with their inclination to delay insulin therapy in people with
Type 2 diabetes [60]. Hesitation to initiate insulin therapy
may also stem from a view that Type 2 diabetes is not a
serious condition or if the provider perceives that lifestyle
changes should be sufficient to treat the individual.
Moreover, some providers may find diabetes management
labour-intensive because of the continuous monitoring and
adjustment required [61]. Providers may also be worried
about the fine line between good glycaemic control and
hypoglycaemia. Alternatively, some providers have reported
being frustrated because of the unpredictable prognosis of
diabetes as, after all, complications may occur despite their
best efforts. Finally, providers are aware that the manage-
ment of diabetes depends mainly on the affected individual
and, while providers acknowledge that making lifestyle
changes is sometimes a great struggle, they may also be
frustrated for not having sufficient training to promote such
behavioural changes. The vast number of observed negative
attitudes among physicians is unfortunate as physicians may
also convey their attitudes to their patients.
Conclusion
Successful diabetes self-management requires that individuals
with diabetes frequently monitor their blood glucose levels
and take required actions in order to keep it within a
physiological level. Beyond glycaemic control, other benefits
of healthy nutrition and physical activity are also stressed.
Good self-management aims at reducing the risks of diabetic
complications and improving the individual’s quality of life.
Self-management is a continuous process and comprehensive
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Diabetic Medicine ª 2012 Diabetes UK
 Review article
concordance with the treatment plan is unlikely a norm.
Individuals have various reasons for not adhering to their
treatment regimen and, in order to improve glycaemic
control, all measures possible should be employed to identify
any barriers for good diabetes management. In this paper,
some of these individual and environment-related barriers
were reviewed.
Funding sources
This study was supported by grants from the Signe and Ane
Gyllenberg Foundation, Folkh€alsan Research Foundation
and Wilhelm and Else Stockmann Foundation.
Competing interests
None declared.
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