A picture emerged of the different diabetes self-care coping strategies across various patient types (see Table 1) [22–24]. Three major categories were identified and capture a wide range of self-care coping strategies: 1.) self-care health value (the value the patient places on diabetes self-care as it relates to his/her health on a continuum from high to low), 2.) self-care responsibility (who is responsible for self-care, which varied from complete personal responsibility to reliance on others for some areas such as diet, or denial of responsibility for self-care), and 3.) self-care coping strategies (five self-care coping strategies or themes were identified: planning of diet and exercise activities, testing, recording, assessment of blood glucose information, and adjustment of diet and exercise activities).
Three patient types, using type in Weberian sense [22–24] could be distinguished, which were labeled: 1.) "proactive manager," 2.) "passive follower," and 3.) "nonconformist." Distinct differences were found in self-care coping strategies across the three patient types (see Figure 1). The patient types responses to each theme varied as detailed below:
Proactive manager
The proactive manger adopts a healthy lifestyle. Many said that they viewed their diabetes as a condition, not a disease, which they had to manage. Although the numbers were small, there were more male proactive managers and most were using insulin or a combination of oral medication and insulin. The three key self-care characteristics of the proactive manager are: 1. high self-care value; 2. acceptance of personal responsibility for most aspects of diabetes self-care; 3. active planning of glycaemic control activities (testing, recording, assessment of blood glucose records), and adjustment of self-care as required (see patient en vivo quotes below). A proactive manager values the relationship between self-care and his/her ability to positively influence metabolic control, especially with daily blood glucose readings. A proactive manager takes a proactive approach to their self-care by using such strategies as reading product labels, planning meals, and assessing medication and blood glucose records for patterns. The proactive manager is very assertive with health care professionals and frequently questions things they do not understand, and many would also negotiate self-care treatment goals. However, it should be noted that some proactive managers are comfortable with the more complex self-care strategies, such as matching insulin to food, and some are not as flexible with self-care adjustment.
Self-care Health Value
"Since I got the meter for the blood tests, I think that I have managed it better than I used to. When I'm in control, I have peace of mind." (MI1)*
"My general health is a lot better since I have been treating it for diabetes." (MO2)*
Self-care Responsibility
"My family all accept the fact that I'm a diabetic, but they all accept the fact that I take care of my diabetes myself, and that if I'm in trouble I would ask them or tell them what I need. Other than that they all depend on me instead of I depending on them." (FO/I3)*
Self-care Coping Strategies
Planning
"I do plan the meals now and we don't do anything greasy or anything like that." (FD4)*
"I read every label; I must be the greatest label reader in the country." (FO/I3)*
"The one thing that I'm very conscious of is sugar and fat. I'm getting more aware of it, where I'd buy say like tinned stuff and I'd never questioned it, but now I am. The stuff I would take months ago, now I wouldn't take it." (MO2)*
Testing, recording and assessment of blood glucose information
"The first thing in the morning, it's a ritual now, the first thing I go to is my meter, and I check my blood with the meter. I would enter that into a diary, so it is recorded in two ways on the meter and in the diary." (MO2)*
"I probably over check, about four times before meals. What I want, you see, is to know what dose I need to take with my meal." (MI5)*
Adjustment of self-care
"I was much higher in the beginning, I'd often be eight or nine, but since I have been on a diet and stuck to the diet nothing goes over five or six." (FD4)*
"I feel quite free to ask him questions (doctor), and I find the nurses in the hospital are very helpful, very easy to talk to, and very easy to get information from." (FO/I3)*
"Well I intend to drop in (diabetes daycare centre at the hospital) after the holiday period is over, because I want to get back down to my 1,200 calorie diet and get my sugars down to the single figures." (FO/I3)*
"If my reading was high, I would do the exercise bike for a few minutes." (MI1)*
"If say I'm on holiday, or if I'm doing something that's not normally part of your routine, it's a bit more difficult. You get sugars that are over ten, but that doesn't bother me that much because, that's the reason I check (blood glucose) as frequently as I do. If I do find it over ten, I can always give more insulin, and that's the benefit of doing the rapidly acting insulin regimen." (MI5)*
"I have been on holidays with other people with diabetes, and they said, 'oh I'm having two drinks tonight and I'm going to have a dessert for my dinner, so I'm going to up my insulin tonight.' I feel that would put your control out completely." (FO/I3)*
* Patient Codes: Gender M = Male, F = Female; Regimen D = Diet, I = Insulin, O = Oral; O/I = Oral/Insulin; and patient ID number at the end
Passive Follower
The passive follower prefers structure to flexibility, with no variation in medication or meal times. Most of the passive followers had type 2 diabetes and used only oral medications. The key self-care attributes that define a passive follower are: 1. consistency in self-care; 2. reliance on others (family or healthcare professionals) for some aspects of self-care; 3. resistance to change once the routine or pattern has been established (see patient en vivo quotes below). The passive follower prefers consistency in their daily routine in order to cope with the burden that diabetes self-care places on their life. A characteristic that most of the passive followers shared was keeping blood glucose records. It should be noted, however, that the passive follower does not assess or change, his/her self-care independently, even if blood glucose readings indicated there is a problem. Passive followers want to fit into the ideal of the "perfect patient," one who conforms to the "ideal standards," even if this means forgoing an activity. However, passive followers will admit to breaking their prescribed dietary regimen some of the time.
Self-care Health Value
"It makes life simpler to kind of follow what you're supposed to be doing anyway." (FO6)*
"I stay fairly constant and fairly level. It's only when you change the routine that maybe things go out of sync." (MI7)*
Self-care Responsibility
"As I say I have complete trust in him (GP). Whatever he says, I abide by it, or I try. He seems to have it covered, and as I say, I trust him." (MO8)*
"The GP would make me more aware if there was an increase in my problem. As I say with the GP, he would say, 'we have to watch those figures. Your weight, you have put on weight,' he would make me aware of all of these things." (MO8)*
"Oh my wife does the cooking. My wife knows better than I do. I think she knows what I'm supposed to have." (MO9)*
"You're watching it all the time. I suppose you can't do lots of things that you would want to do, even in the line of walking or gardening." (FI10)*
"Like you're not suppose to have chips now or anything like that, but sometimes I'd have chips, because I think I deserve a little treat, my life is boring enough as it is." (FO11)*
Self-care Coping Strategies
Planning
"I went through my diet with the dietician. Mondays to Fridays very regimental, the amounts are the exact same (food portion sizes), and the units of insulin have never changed." (MI7)*
"All that I have done is cut out all of the sugars. I don't take any sugar. I don't take cakes, biscuits or anything like that. If I want something as a snack, I take a piece of fruit." (MO8)*
Testing and recording of blood glucose information
"About four times a week I usually take my blood sugar and it's in the range. I still keep a diary (blood glucose records). I'm up to the ninth diary since I got diabetes." (MD12)*
"You can see where on your diary, if it keeps within the regular, I know they say four to seven, but I suppose if it's still under 10 it isn't too bad. I actually said to the doctor, there was one day, and he was looking at the diary, and it was 11 something when I went to bed, but it was still eleven in the morning. You know, for no apparent reason, something like that can happen, but he said all the rest are quite ok, they are well within the acceptable range. So he said I wouldn't worry too much about an occasional thing like that." (FD13)*
*Patient Codes: Gender M = Male, F = Female; Regimen D = Diet, I = Insulin, O = Oral; O/I = Oral/Insulin; and patient ID number at the end
Nonconformist
The last patient type, the nonconformist, did not adopt a healthy lifestyle. They do not follow many of the activities of their self-care regimen, especially prescribed dietary and activity changes. Most of the patients in the nonconformist group were using insulin or a combination of oral medication and insulin. Key characteristics for the nonconformist are: 1. lack of personal responsibility for diabetes self-care; 2. low self-care health value; 3. lack of planning, assessment, or adjustment of self-care (see patient en vivo quotes below). A nonconformist does not feel responsible for their self-care, and is often in denial about how diabetes will affect their future health. A nonconformist does not place much value on self-care and some even admit that they know what they are supposed to do but can't be motivated to make changes. A nonconformist would not actively plan meals or exercise, test blood sugar, or assess their self-care routine. Conversely, even though the nonconformist does not follow his/her dietary regimen and does not test blood sugar, he/she will admit to taking their medications.
Self-care Health Value
"I just don't change easily, I couldn't be bothered, I suppose. I'm quite happy with what is bad for me. I still go ahead at times and eat things that I know I shouldn't be eating." (MI14)*
"I said to him (doctor), 'You'll get as much information from me as you would from my diary as there is nothing in it." (FO/I15)*
Self-care Responsibility
"Maybe I'll develop some complications of diabetes, eye problems you know, kidney problems, what will happen in the future will happen." (MI14)*
"Diabetes has no effect on my life. It has no effect on me to the extent, as I say it was just by chance that it was diagnosed. It could have been there for years. I could have gone for two or three more years with diabetes without knowing it." (MD16)*
Self-care Coping Strategies
Planning, testing and assessment
"Sometimes I have the awful habit of feeding everyone and leaving myself to last, and then you know that you have to have it (food), and when that occurs you're inclined to shoving it down, and then the sugars go up." (FI17)*
"I'd only walk around if it was fine weather and if I was to go from A to B. If I could walk there that's fine, but don't ask me to be going for a walk. Do you know what I mean?" (FI17)*
"I don't test at all (blood sugar testing). I haven't tested in awhile, because my meter, either the battery is gone or something like that, and I haven't got time to get another meter." (MD16)*
"If I want to get something done I will set myself targets, but as for targets again where my diabetes is concerned, not really. I just can't seem to be motivated to do anything about my diabetes." (MI14)*
* Patient Codes: Gender M = Male, F = Female; Regimen D = Diet, I = Insulin, O = Oral; O/I = Oral/Insulin; and patient ID number at the end