Perceptions of Diabetes Self-Care Management Among Older Singaporeans With Type 2 Diabetes: A Qualitative Study

Abstract

Background: 

Given the global shift in aging populations and the associated increasing prevalence of diabetes, it is critical to explore new approaches in diabetic self-care management. In Singapore, what has been overlooked to date is an in-depth, contextually based examination of the needs, expectations, and barriers faced in self-care management by older adults with Type 2 diabetes.

Purpose: 

This study aimed to explore the experiences of older Singaporeans with Type 2 diabetes in diabetes self-care management to understand their perceived needs, expectations, and barriers associated with their diabetes self-care management.

Methods: 

A descriptive qualitative approach using focus group discussions was adopted. Purposive sampling was used to recruit older adults with Type 2 diabetes from Singapore’s three main ethnic groups, namely, Chinese, Malay, and Indian, through the diabetes centers of two hospitals. Four focus groups, including two groups of Chinese, one group of Malays, and one group of Indians, were conducted. Thematic analysis was used to analyze the data set for emerging themes that relate to the experiences of participants with diabetes self-care management.

Results: 

The four major themes related to the experiences of participants with diabetes self-care management that emerged were as follows: (a) “Diabetes is genetic, destined, and not serious; complication, let it come”; (b) “Diabetes self-care is difficult”; (c) “I don’t know diabetes”; and (d) “Doctor and nurses are important facilitators of self-care management.”

Conclusions/Implications for Practice: 

Findings have important implications in Singapore as well as in other Asian countries where populations are also aging and diabetes prevalence is increasing. The findings provide new culturally focused insights for clinical patient education within the Southeast Asian context to improve diabetes self-care management of older adults.

Introduction

In Singapore, diabetes is among the top 10 causes of death, with an incidence of people with Type 2 diabetes aged 18–69 years that has increased from 8.2% in 2004 to 11.3% in 2010. Of all patients in the National Health Group, 12%–15% were patients with diabetes in 2008, with half of them having Type 2 diabetes aged 45–64 years (^{Heng, Sun, Cheah, & Jong, 2010}). A higher incidence of Type 2 diabetes was found in Malays and Indians who were aged <65 years and in Chinese who were aged ≥ 65 years. The population of those over 60 years old is anticipated to increase from 332,000 in 2000 to 835,000 in 2030 (^{Chen & Cheung, 1998}). This statistical revelation signals an impending health issue that could inflict heavy burdens not only on the Singaporean national budget and healthcare resources but also on individual older adults and their caregivers, families, and communities. More importantly, the burden of disease associated with diabetes is further compounded by an aging population in any given society.

Literature Review

Globally, diabetes was the direct cause of an estimated 1.5 million deaths in 2012, and high blood glucose accounted for another 2.2 million deaths (^{World Health Organisation, 2016}). In Singapore, diabetes is currently the second leading cause of morbidity and mortality (^{Ministry of Health [MOH], 2016)}. Complications arising from diabetes were documented to include an increase in new incidences of kidney failure from 46% in 1999 to 62% in 2009, with a corresponding increase in end-stage renal disease from 28% in 1999 to 44% in 2009 (^{Health Promotion Board, 2011}). In addition, the Singapore National Registry of Diseases reported that, in 2014, about one in two heart attack cases had diabetes, whereas two in five stroke cases also had diabetes (^{MOH, 2016}). In addition, a recent study revealed that there are now more than 1,500 amputations per year in Singapore due to complications arising from diabetes. The disease has also been associated with a threefold increase in mortality, of which most was related to cardiovascular diseases, and a threefold to sevenfold increase in the risk of coronary artery disease (^{MOH, 2016}).

It is well recognized that people with diabetes need to actively engage in self-care activities such as diet control and regular physical exercise, follow prescribed medication regimes, self-monitor their blood glucose level regularly, go for regular foot screenings, follow up with medical consultations, and manage personal stress levels to control their condition (^{World Health Organisation, 2016}). However, existing literature also reported that self-care behaviors in diabetes management are largely influenced by psychological and social issues (^{Beverly & Wray, 2010}; ^{Gucciardi, DeMelo, Offenheim, & Stewart, 2008}; ^{Murphy, Casey, Dinneen, Lawton, & Brown, 2011}). The motivation of patients to self-care is seen to be enhanced by self-confidence, the presence of family support, and positive changes in relationships (^{Murphy et al., 2011}). Social issues such as work commitments and accessibility to healthcare facilities are barriers to attending self-care programs, which are further associated with a lack of knowledge on the disease and limited ways of coping with the condition (^{Gucciardi et al., 2008}). Cultural construct is another factor influencing behavior in diabetes self-care management, whereby personal perceptions of self-management strategies are based on emotions and attitudes toward the disease (^{Furler et al., 2008}). In addition, family support contributes to personal self-efficacy, which has a strong effect on self-care behaviors, leading to increased self-care activities and better health outcomes (^{Beverly & Wray, 2010}). Importantly, self-care management in chronic disease involves psychosocial aspects of coping with the illness (^{Newman, Steed, & Mulligan, 2004}).

Thus far, no Singaporean-based research has examined the psychosocial factors affecting the diabetes self-care management of Type 2 diabetes in older adults of differing ethnic backgrounds. Therefore, we conducted focus group discussions to explore the experiences of Singaporeans living with diabetes to understand their needs, expectations, and barriers with regard to diabetes self-care management. The research questions were as follows: (a) What are the experiences of older adults with Type 2 diabetes in diabetes self-care management? (b) What are the needs, expectations, and barriers of older adults with Type 2 diabetes in diabetes self-care management?

Methods

Design

A descriptive qualitative design was employed using focus group discussions to collect data. Descriptive qualitative design requires that the researchers stay close to their data and present the facts of the case in everyday language (^{Sandelowski, 2000}). This methodology suited the study purpose, as patients experience diabetes as a daily phenomenon. In addition, focus group discussions are conducted in a less threatening environment, which encourages participants to interact to discuss perceptions, ideas, opinions, and thoughts about their experiences with diabetes (^{Sandelowski, 2000}). Our approach used a semistructured interview guide that was developed from the literature and then subsequently piloted. This enables a more comprehensive and systematic process of data collection that also provides more control for the interviewer with a structured question format, allowing a conversational tone to encourage participants to answer in their own ways (^{Melnyk & Fineout-Overholt, 2011}).

Participants

Purposive sampling was used to recruit participants who were visiting the diabetes centers of two major metropolitan hospitals for regular follow-up, medical care, or consultation. The inclusion criteria were participants who were (a) a Singapore citizen or Singapore permanent resident; (b) 50 years old and above; (c) of Chinese, Malay, or Indian ethnicity; (d) clinically diagnosed with Type 2 diabetes; and (e) able to communicate in English.

Sampling was determined using data saturation principles, with continual sampling until new data collected did not provide any new insights or themes on the phenomenon being studied (^{Bowen, 2008}). In the current research, saturation was achieved when no new participant was necessary to further elaborate on the complexity of human issues (^{Marshall, 1996}).

Data Collection

The interviews were conducted using a semistructured interview guide based on the diabetes self-management framework, which solicited in-depth testimonies on diabetic self-care management. The interview guide included open-ended questions on self-care activities, including diet modification, physical activity, glucose monitoring at home, foot care, medications and medical follow-up, and resources such as self-care and informal, formal, and medical care (^{Mathew, Gucciardi, De Melo, & Barata, 2012}). The interview guide was revised following a pilot study with a Chinese focus group.

Four focus groups (two groups of Chinese, one group of Malays, and one group of Indians) were conducted in English at the diabetes centers of two hospitals between January 2014 and March 2014. Fourteen participants including seven Chinese, four Indian, and three Malay participants took part in the focus group discussions.

The participants were initially briefed on the aim of the study and the expected conduct of the discussion. Each participant’s data were given a code for identification to ensure confidentiality. The first author, a doctoral student trained in healthcare qualitative research and with many years of experiences as a focus group facilitator, was the group moderator, whereas the site investigator assisted in observing and note-taking in all four groups. The focus group discussions were audiotaped, and the note-taker documented the group exchanges to assist the transcriber in differentiating the participants’ comments. Each focus group lasted for approximately 60 minutes. To avoid language bias, participants were grouped by ethnicity in each discussion group, with only those who could speak fluent English included in the study. To ensure consistency across the four focus groups, all of the discussions were moderated by the first author.

Data Analysis

The data were transcribed verbatim, and data analysis was undertaken using the framework of a six-phase thematic analysis (^{Braun & Clarke, 2006}). The first phase involved the first author immersing herself in the data by repeated readings to deeply know the meaning of the content. The second phase involved generating the initial codes, whereby the data were coded using an inductive approach to identify the initial ideas that emerged from the data. The third phase was about searching for themes, whereby convergence and divergence techniques were first used to analyze the initial codes and then the codes were sorted to identify potential themes. In this phase, the first author clustered similar codes among the three ethnic groups into subthemes. The fourth phase involved a review of the themes, whereby the potential themes were reviewed and refined to reveal an overall story. The fifth phase involved defining and naming the themes, whereby the data were examined with a focus on similarities and differences between the three ethnic groups on diabetes self-care to produce the main themes. Throughout the phases of analysis, the first author adopted the language of the participants to generate the codes and described the subthemes and main themes.

Rigor

Rigor was ensured by checking the feasibility and adequacy of the semistructured interview guide to elicit appropriate and sufficient data to achieve the study aim through a pilot study. The questions in the guide were then modified based on the advice of diabetes specialists. Audio recording and verbatim transcription of the discussions also ensure the authenticity of the data quality. Data analysis was counterchecked by two authors to reach thematic agreement and to ensure accuracy in the final report. Thereafter, all of the research team members validated the findings by reviewing and agreeing with the themes.

Ethical Considerations

Ethical approval was granted by the National Health Group Domain Specific Review Board (Reference number 2013/00773). Written consent was taken from the participants before the commencement of each focus group.

Results

Twenty participants were recruited for the focus group discussions. However, six participants withdrew from the study because of reasons such as sickness or overseas travel. The remaining 14 participants were aged 50–71 years (mean = 58 years), of which nine were male and five were female. In terms of employment, 10 worked full-time, 1 worked part-time, and 3 were retirees. All focus group attendees had been clinically diagnosed with Type 2 diabetes and had at least one other comorbidity, which included hypertension, hyperlipidemia, and heart disease.

Emerging Themes

Seven subthemes and four main themes emerged from the experiences of the participants discussed during the focus groups, representing the participants’ needs, expectations, and barriers in diabetes self-care management, as shown in Table 1. The main themes include (a) “Diabetes is genetic, destined, and not serious; complication, let it come”; (b) “Diabetes self-care is difficult”; (c) “I don’t know diabetes”; and (d) “Doctor and nurses are important facilitators of self-care management.”

TABLE 1.: Themes and Subthemes Emerged

Diabetes is genetic, destined, and not serious; complication, let it come

There were both a convergence and a divergence of perceptions regarding the onset of diabetes within and across the three ethnic groups, which are reflected in the subthemes “it is a family genetic condition,” “diabetes is not cancer,” and “complications, let them come.”

1. It is a family genetic condition

There was a convergence of belief that diabetes was a genetic condition among the ethnic groups, particularly the Indian group whose family history of diabetes was strongest, as they stated:

Actually, my father, grandfather had it and that’s the thing. If grandfather has it, the next generation will have…. I was prepared. (Indian 1)

Actually, I anticipated because of genetic factor. The thing is that my dad had diabetes…. Followed by my elder brothers, two elder brothers, and then when they told me I had diabetes, I wasn’t really surprised about it. I was quite prepared for it. (Indian 2)

For me, more or less I expected it. My mother’s side are all diabetics. My grandmother, my mother had. So it wasn’t a shock to me…. (Indian 3)

You see my parents, my mother had diabetes…. So when I was confirmed as a diabetic, okay, they said it could be through family genetics, so on and forth…so I accepted it…. (Indian 4)

2. Diabetes is not cancer

Diabetes was perceived as “not a serious disease” because it was not deadly or infectious when compared with cancer or acquired immune deficiency syndrome. This perception seemed to influence the sense of urgency for diabetes self-care as indicated by an unaffected attitude, as stated:

Diabetes for me also is not a serious sickness, in my mind, lah…. It (is) not like cancer…by one year or two years (one dies). So this one (diabetes), I don’t keep it in my mind…. (Chinese 3, Group 1).

Diabetes is not a very scary, very scary sickness… even if everybody knows…. it is normal…because it is not AIDS or can pass to somebody. (Chinese 3, Group 1).

3. Complications, let them come

All participants from the four focus group discussions expressed an awareness of risking diabetes-related complications due to poorly controlled diabetes. Despite this knowledge, some participants acknowledged their risks but simultaneously stated a “do-nothing” approach and expressed a loss of control in managing diabetes and willingness to accept the consequences, as stated:

These complications, if you think too much, it will stress you out especially…. Let it come. If it comes, it comes.... (Indian 4)

If that (amputation) is meant for me, that’s the right thing. But maybe I will invent my own foot. (Malay 2)

Diabetes self-care is difficult

There were thematic convergences of perceptions that diabetes self-care is difficult, despite the recognition by the participants of the importance of this self-care. This perception of difficulty in increasing self-care activities was expressed by participants in all four groups. There was a sense of resistance to lifestyle modifications to increase diabetes self-care activities, which was reflected in the subthemes “eating is meaningless,” “it is cultural,” and “no time for physical exercise and forgetting medicine”

1. Eating is meaningless

With regard to changing their diet to eat healthier foods, there was convergence of negative feelings among the participants in the four groups. The Chinese group viewed eating with a controlled diet as meaningless, and having to limit food choices was perceived as unappetizing. In contrast, the Indian and Malay focus group discussants were unwilling to reduce or forgo their favorite foods, as stated:

It makes me feel very frustrated. I am also a human being, I can eat anything. (Chinese 3, Group 2)

You must cook it yourself; food must have no salt, no taste, completely…bland.... (Chinese 1, Group 1)

I am not happy. Your thing you like to eat, for example, lotong, mee-rebus, all these have good things in taste in life…. To reduce it, to eat biscuit and roti, it’s hard, but what to do. (Malay 2)

Basically we Indians, we want rice. If never eat rice, we feel as if we have not eaten…. (Indian 4)

2. It is cultural

Both the Indian and Chinese participants expressed that eating was a cultural aspect of life and so it was difficult to change eating habits and choices of food. The Indian participants expressed a strong resistance to reducing consumption of traditional carbohydrate-loaded foods such as Indian sweet desserts and rice that are daily staples. Similarly, the Chinese participants expressed that they could not resist family and peer pressure to consume high-calorie food during festivals and social gatherings, as stated:

…you know Indian food and favour…never mind once in a while just eat…so any excuses available would be New Year celebration and Deepavali (Indian New Year).... (Indian 2)

…So once in a while, we just whack. Last two months, Deepavali and December was Christmas. My blood sugar is fluctuating now. (Indian 3)

If you are social, you just enjoy yourself. Don’t think about my medicine, my injection. (Chinese 2, Group 1)

3. No time for physical exercise and forgetting medicine

There was a convergence of knowledge that physical activities and medication could improve diabetic conditions. However, most participants in the four groups cited work commitments as the main cause of their physical activity restrictions and “forgetfulness,” which was seen to disrupt their medication regime, as stated:

Because most of time I’m at work, my brain is totally dry by the time I reached home. It is 9 or 10, too tired, mentally stressed, physically. (Indian 1)

By the time I get home in the evening, it is easily 8 or 9 o’clock, I am so physically tired. (Indian 3)

For me, I work long hours, so it is very difficult (to exercise). (Malay 2)

…whether I skip medicine or not depends on work, what time I come back…. (Indian 4)

I cannot manage my diabetes due to work lah…. sometimes, when I free, I sit down…go take my medicine. But after two to three days, I forget everything again. (Chinese 3, Group 1)

If I do work, engrossed in work, forget to take my medication...sometimes I forget my medication also. (Malay 1)

I don’t know diabetes

There was a widespread expression of frustration and unhappiness over the inadequacy of health information and their lack of understanding about diabetes converging in all the participants. There was also a sense of confusion, as participants felt that their experiences did not match their expectations that increasing diabetes self-care activities would help control their diabetes condition, as they stated:

I do not know what is diabetes…. The medicine didn’t work. I run every day, I exercise every day. I run every day but it didn’t work (there was no improvement)…. Something must be wrong somewhere. (Chinese 1, Group 1).

My doctor told me he can’t increase my metformin further; he was telling me that it helps in the intervention…. I don’t know what he said. (Indian 4)

People say leg will cut but…I can still feel the senses…just exaggerating. I do not know how they slowly build up, these slowly build up is not many people can realise it. (Indian 2)

As a patient, I need to know the blood test. For us, 1–100, of course, 100 is very high. But if 1–50, 50 also high. But now 18, 15, all high, but how high? (Malay 2)

Doctors and nurses are important facilitators of self-care management

There was a convergence of perceptions that doctors and nurses were the best professionals from whom to seek advice about diabetes self-care management. This reliance on healthcare professionals for diabetes self-care management may have led to the expressed tendency of participants to focus on getting help and advice only when complications arose rather than as a preventive strategy:

If you got a symptom or whatever it is, go and consult your company doctor. (Chinese 2, Group 1)

It is good that we have a regular doctor or somebody to call us and talk to us…. (Indian 1)

Diabetes comes, no need to worry…listen to the doctor’s advice…. When you are sick, you go and see company doctor…. (Chinese 2, Group 1)

Doctor said take medicine, so take lah. No idea to think of. (Malay 1)

Discussion

There were both a convergence and a divergence of perceptions with regard to diabetes as a disease condition among the ethnic focus groups. There were varying expressions of individual health beliefs, which, to a large extent, was seen to influence the attitudes and motivation of participants toward diabetes self-care management. One Chinese participant perceived diabetes as a less serious disease than cancer and believed that life should go on as usual because work is more important. On the other hand, the Indian focus group stated the strong belief that their diabetic condition was due to genetic factors, as all the Indian participants quickly listed out family members who had had diabetes and expressed an inevitable acceptance of diabetes. One Malay participant believed that disease is predestined and was prepared to accept the onset of diabetes-related complications.

The Chinese perception of diabetes as not a serious disease may be explained by the Health Belief Model (^{Glanz, Rimer, & Viswanath, 2008}), whereby the construct of perceived severity predicts that individuals are less likely to engage in behaviors to prevent a health problem or reduce its effects if they perceive a given health problem as having less serious consequences. Correspondingly, a study found that participants who perceived diabetes as a severe condition were more likely to increase diabetes self-care activities (^{Ayele, Tesfa, Abebe, Tilahun, & Girma, 2012}).

Most of the participants in the three groups shared the belief that diabetes had hereditary predictability. Notably, the Indian focus group strongly testified to believing that their diabetic condition was due to genetic factors. All of the Indian participants quickly listed family members who had had diabetes and expressed an inevitable fatalistic acceptance of diabetes. Indeed, several studies found a genetic link to Type 2 diabetes and established that Asian Indians were more insulin resistant than Whites (^{Abate, & Chandalia, 2001}; ^{Martin, Palaniappan, Kwan, Reaven, & Reaven, 2008}; ^{Mente et al., 2010}). Asian Indians have been reported to have poorer glucose tolerances than Chinese and Malays (^{Gujral, Pradeepa, Weber, Narayan, & Mohan, 2013}). It was also noted that diabetes prevalence in Singapore was the highest in the Indian population (15.9%), followed by Malays (11.4%) and Chinese (6.4%; ^{Bhalla, Fong, Chew, & Satku, 2006}). However, it was also found that inherited genetic susceptibility constitutes 40%–70% of risk for diabetes and that the eventual development of Type 2 diabetes is due to an interaction between inherited genes and environmental factors (^{Murea, Ma, & Freedman, 2012}). This suggests that Type 2 diabetes and its related complications may be preventable by controlling the self-management of environmental factors such as diet intake, physical exercise, and stress. The findings on individual health beliefs among the three ethnic groups highlight the need for targeted patient education to address prevailing misconceptions and to emphasize self-care prevention of diabetes-related complications based on scientific evidence and sociocultural knowledge.

The participants in the three ethnic groups shared similar perceptions on the importance of dietary control. The participants acknowledged the centrality of using dietary control to maintain satisfactory blood glucose levels to prevent diabetes-related complications. However, all expressed difficulties in exercising this control. Those who were employed cited work commitments as the main barrier to diabetes self-care activities such as eating healthily, engaging in routine physical exercises, and adhering to medication. When working, they had to eat at Singapore’s food centers and hawker markets, where healthier choices of food are limited. Indeed, it has been reported that work commitments are the predominant barrier to self-care faced by men (^{Cherrington, Ayala, Scarinci, & Corbie-Smith, 2011}). Some participants deemed healthy food as unappetizing, and some Chinese participants particularly expressed the idea that life with dietary control would be “meaningless.” Indeed, studies have shown that the adherence of patients with diabetes to healthy eating is less than optimal and that older adults with long-established eating habits have more difficulties in keeping to a strict diet plan than younger adults (^{Green, Bazata, Fox, Grandy, & SHIELD Study Group, 2007}; ^{Nestle et al., 1998}; ^{Woodcock & Kinmonth, 2001}).

An added barrier to dietary control in this cohort in Singapore was festive celebrations and socializing, as most participants, particularly the Chinese, did not see the need to control their diet during such events. Furthermore, there was significant social pressure to eat high-calorie food during social gatherings. It was noted that Chinese beliefs emphasize socializing through food and mealtimes, which helps maintain and deepen relationships with family members and friends (^{China Culture Organisation, 2015}). Similarly, Indian sweets are significant in the Indian culture as they are considered symbolic when eaten during weddings and the Indian New Year and often taken as desserts after meals (^{IndiaNetZone, 2008}). Inevitably, the cultural aspects of eating are socially normalized for both the Indian and Chinese cultures, and dietary diabetes control was seen to disrupt the participants’ routines and rituals. This disruption in diet control may not be temporal, as Singapore is multicultural where festive celebrations take place throughout the year with the predominant ethnic groups sampled celebrating most ethnic festivals. In addition, Singapore, being a cosmopolitan country with migrants and foreign workers, is popularly known as a “food paradise” where people place great importance on the social enjoyment of food from different nationalities and ethnic groups. It can be contended in this context that the restriction of food choices imposed by diabetes becomes weaker in face of these social compulsions.

Most of the focus group participants who were employed expressed difficulties engaging in regular exercise as they worked irregular hours or were physically tired after work. The participants viewed these difficulties as barriers that affected their propensity to self-care, leading to a fatalistic sense of loss of control, which was seen to also affect their self-confidence in managing their other daily activities.

With regard to diabetes medications, all participants recognized the importance of improving their current health, with those who were employed citing “forgetfulness” as the main reason for omitting their medications. On the other hand, the unemployed or retired participants testified to taking their medication as prescribed and citing this as because they were “always at home.” This corresponds with the findings of another study that found that low conscientiousness often involves health behaviors such as poor adherence to medication (^{Jokela et al., 2014}). On the contrary, studies conducted in Taiwan indicate peer support for self-care behaviors to be an important predictor of high levels of medication adherence among Chinese older adults (^{Chiou, 2014}).

With regard to expectations of healthcare providers, the participants expressed a need for clarity about their diabetic condition. Older adults with diabetes have been found to face difficulties in adjusting to the necessary lifestyle changes because of inadequate support from healthcare professionals after hospital discharge (^{Baggio, Sales, Marcon, & Santos, 2013}). On the other hand, a study on the perspectives of healthcare providers about patient education revealed that organizational barriers such as doctors and nurses’ heavy workloads, work frustration, and language barriers with patients contribute to inadequacy in patient education (^{Noor Abdulhadi, Al-Shafaee, Wahlström, & Hjelm, 2013}). As the prevalence of diabetes is inversely related to the healthcare-professional-to-patient ratio, it is likely that the effectiveness of the current approach to health education for diabetes self-care will be severely limited.

These participants felt that Singapore’s doctors and nurses had an important role as health educators. They testified that their main strategy in managing diabetes was to get advice from their healthcare providers. Most focus group participants preferred personalized advice during medical follow-ups rather than getting information from other sources such as the Internet or diabetes guides, which require time to search. However, the current shortage of doctors and nurses makes it difficult to provide continuum of care and substantial support to patients with diabetes. A potential strategy to alleviate this shortage is adopting peer support, which was found to have a positive effect on self-care management of Chinese patients with Type 2 diabetes in Taiwan (^{Chiou, 2014}; ^{Chiou, Huang, Lin, & Wang, 2016}).

Limitations

There are a number of limitations in this study. First, the generalizability of the study findings may be limited due to the recruitment and interview of only three different ethnic focus groups. In addition, the use of a semistructured interview guide may have precluded the elicitation of in-depth themes.

Conclusions

The participants from the three ethnic groups that were sampled in the focus group discussions shared similar perceptions with regard to their needs, expectations, and barriers in diabetes self-care activities. The key psychosocial factors influencing these elderly Singaporeans’ diabetic self-care management of Type 2 diabetes were as follows: perceived individual health beliefs, which affected their attitude and motivation to increase self-care activities; perceived difficulties in self-care activities such as adopting healthier food choices, which were seen as unappetizing and not culturally congruent; work commitments that affected their regular physical exercise patterns; “forgetfulness,” which disrupted their medication regime; and, finally, a high perceived need for information from doctors and nurses. We contend that these findings provide new perspectives on key issues that may be addressed in the design of future self-care interventions to meet effectively the needs of older Singaporean adults with diabetes.

Implications for Practice

These findings have important implications in Singapore and other Asian countries where populations are also aging and diabetes prevalence is increasing. The findings provide new insights for clinically based and culturally targeted patient education that, for example, provides psychosocially based educational interventions and addresses the generational and cultural misconceptions that diabetes is “not a serious disease,” which currently detracts from the effectiveness of diabetes self-care behavior promotion efforts. Culturally tailored patient education on diet modifications may include using healthier recipes to make cultural foods such as replacing coconut milk in Indian curry with skim milk, which is healthier for patients with diabetes.