This study conducted interviews to gather insights into the reasons for not attending DSME among adults with type 2 diabetes. One of the two main reasons for non-attendance identified in this study was participants’ perception they did not need DSME. This arose from individuals’ self-efficacy to manage their condition, the low priority they gave their type 2 diabetes and having limited information/knowledge about DSME. The second main reason for non-attendance were practical barriers and these encompassed structural issues relating to transport and the programme’s schedule. This discussion chapter will focus on how these barriers relate to the constructs in ABM and previous literature, as well as consider the ways in which attendance to DSME can be optimised.
Individuals’ self-efficacy regarding control over their type 2 diabetes and knowledge about their condition were frequently cited as reasons for non-attendance in the current study. These findings support previous research that has found perceptions of knowledge and competency in self-managing one’s type 2 diabetes as barriers to DSME attendance [29, 30]. According to ABM, ‘predisposing factors’ which can impede health service use include high self-efficacy such as knowledge of one’s health condition and ability to manage one’s condition . This construct, therefore, mirrors the findings in the current study whereby key reasons for non-attendance included having good knowledge about one’s condition and the necessary skills to self-manage their type 2 diabetes.
The present study also found that health professionals may influence individuals’ perceived need to attend DSME. Physicians who conveyed to individuals that their condition was not serious often led individuals to believe they did not need to take further action. This suggests individual factors (e.g. self-efficacy) are not the sole determinants of perceived need but external factors, such as a physician’s assessment, also play a role in individuals’ appraisal of whether they need to attend DSME. These findings are congruent with the ‘need factors’ construct of ABM which specifically distinguishes the difference between health professionals’ and individuals’ judgement of health status and, in turn, recognises the influence health professionals can have on individuals’ engagement with a particular health service . This supports the use of ABM in mapping out the reasons for not attending DSME. In light of this, it is important that health professionals accurately assess and convey to individuals the status of their health and do not undermine or over-emphasise the severity of an individual’s type 2 diabetes. Undermining the severity of an individual’s diabetes may, as our study suggests, undermine motivation to attend DSME. On the other hand, over-emphasising the severity of an individual’s type 2 diabetes may lead to undue anxiety . Health professionals therefore play a key role in helping an individual understand the severity of their type 2 diabetes and, in turn, influencing individuals’ decision about whether to participate in DSME.
A novel barrier to attendance arising from the current study was the pre-existing receipt of support from a primary care physician. This finding is congruent with the ‘enabling factors’ category of ABM which outlines that the availability and nature of support can facilitate or impede health service utilisation . However, it contrasts with previous findings in the field which have found lack of support and poor physician-patient relationships as barriers to attendance . Our findings may be explained by a study by Gucciardi and colleagues  which found that some individuals perceive primary care physicians to provide the same coverage of diabetes education and lifestyle modification skills training as DSME. Similarly, another study found that individuals reported missing diabetes clinic appointments because they were already seeing a family physician or diabetes specialist . These findings suggest that individuals who already feel well looked after and monitored may have their needs being met already and therefore, do not need to attend DSME. In such a situation, it may be beneficial for the individual, using their knowledge of their type 2 diabetes and self-management behaviours, and the physician, using their knowledge of DSME, to work together to consider whether DSME can offer any additional benefits over and above their pre-existing care and support – and whether such benefits are worth the costs of attending (e.g. time, finance).
The low prioritisation of one’s type 2 diabetes was also found to be a reason for non-attendance among some individuals. This is in line with the ‘predisposing factors’ construct of ABM which outlines that attitudes towards one’s health and service use can facilitate or impede health service utilisation . Attributing a low priority towards one’s type 2 diabetes has been cited as a key reason for non-attendance elsewhere in the literature [30, 35].
In the current study, low prioritisation of one’s type 2 diabetes was evident among individuals with a comorbidity whereby they perceived some conditions as more serious than others and prioritised another health condition over their type 2 diabetes. This supports similar findings that the burden associated with having and managing a comorbidity can impede resources and motivation to manage one’s type 2 diabetes , particularly when the disease and treatment burdens are greater for the comorbid condition than the burdens of type 2 diabetes [37, 38].
Disease and treatment burden from comorbid conditions can also have significant detrimental impacts on mental health and wellbeing . This emphasises the need to acknowledge (and manage) such comorbidities when individuals are referred to DSME – particularly given associations between greater life satisfaction and wellbeing and improved treatment adherence .
The low prioritisation some people give their type 2 diabetes may also reflect a culture that perceives type 2 diabetes to be the ‘mild’ form of diabetes, despite its high morbidity and mortality rates . The experiences of individuals in other cultures may differ depending on different cultural perceptions of type 2 diabetes. These findings suggest that health professionals may wish to raise awareness of the complications that could arise from their type 2 diabetes and help facilitate healthy behaviours that can benefit both their type 2 diabetes and comorbidities. Motivational interviewing which involves health professionals working alongside individuals to explore their views about their condition and behaviours, rather than immediately giving advice or referring them to DSME, may also help to better understand the unique views, needs and capabilities of the individual with comorbidity and assess whether DSME would be beneficial [42, 43]. Motivational interviewing can also be used to help people reflect on any ambivalence towards self-management and to help people prioritise what is most important to them in their lives .
Limited knowledge about the content, purpose and benefits of SDE also acted as a barrier to attendance. This finding is in line with the ‘enabling factors’ construct of ABM which outlines that inadequate personal resources, such as limited knowledge about a service, can impede health service utilisation . It also corroborates previous qualitative literature which cite a lack of familiarity and knowledge about DSME as common barriers to attendance . A novel finding in this study was that individuals often attributed limited information about DSME to their primary care physician. Interestingly, however, several studies have found that physicians may feel unable to discuss the benefits, goals and expectations of DSME due to their own lack of knowledge of DSME [46, 47]. This highlights the need to empower individuals with type 2 diabetes to seek information about DSME themselves, rather than relying on their primary care physician as a main source of knowledge. Physicians who have a basic understanding of key sources where people can go to find out more information about DSME would likely be beneficial .
Previous research has also highlighted that a lack of familiarity and knowledge about DSME may stem from information about DSME that is inaccessible . It is therefore crucial that information about DSME, as well as the programme itself, is made available in accessible and acceptable formats such as other languages, easy-read, British Sign Language and audio. The provision of DSME in other languages is highly relevant given that the prevalence of type 2 diabetes is three to five times higher in minority ethnic groups compared to the white British population and approximately 10–12 years earlier onset . There is also strong evidence that health literacy – a person’s ability to understand and use information to make decisions about their health – is a strong predictor of health-related knowledge, illness self-management, health service use, health, and survival in people with type 2 diabetes . People with low health literacy levels are more likely to have lower health-related knowledge [50, 51] and self-management [52, 53]. It is therefore critical that information about DSME (e.g. aims, benefits etc.) is provided in a format that is accessible and engaging to people with varying levels of health literacy . The need to adopt and provide an adequate service for all societal groups also supports why a person-centred approach to overcoming barriers and increasing engagement with DSME is of paramount importance.
The final barrier to attending DSME identified in this study were the practical barriers associated with attending, namely conflicts between the programme’s schedule and other commitments and transportation issues with getting to the venue. Both of these barriers have been cited in previous literature  and are in line with the ‘enabling factors’ category of ABM which outlines that practical barriers to obtaining care (e.g. income, other responsibilities) can impede health service utilisation .
Alternative methods of delivering DSME, such as offering the course online or via a mobile application, was well-received by participants and may help to alleviate barriers of time, commitment, mobility and transportation by enabling people to access DSME at their own convenience. This may be particularly pertinent for individuals who work shifts or on zero-hour contracts where it may be difficult or not possible for them to get paid time off work to attend DSME. Indeed, such individuals tend to be those with lower socio-economic status and, in turn, also at risk of poorer self-management outcomes . An additional benefit of online DSME is that it can also be made available to large numbers of individuals at minimal cost . An online DSME programme, called X-PERT Health, has demonstrated significant benefits to a range of diabetes outcomes, such as glycaemic control, body weight, blood pressure and cholesterol . Similarly, in a randomised control trial, a web-based self-management programme for people with type 2 diabetes (called HeLP-Diabetes) improved glycaemic control over 12 months . The offer of online DSME may therefore help to increase attendance and retain individuals by offering DSME at a time and place that suits people’s individual needs.
However, it is important to recognise that some individuals, particularly those with very low socioeconomic status, may be unable or find it difficult to engage with online DSME due to an absence of internet and/or technology (e.g. laptop, tablet, smart phone). To overcome this, additional funding and resources would be beneficial in order to assist individuals in accessing online DSME (e.g. provision of a tablet, free Wi-Fi), or increasing the frequency of DSME so that barriers of time and the programme’s schedule are minimised .
A strength of this research is its use of ABM as a well-supported model to illuminate the barriers to attending DSME. All three constructs of ABM were congruent with individuals’ reasons for not attending DSME. In particular, ABM specifically distinguishes the influence that health professionals’ judgement of health status can have on someone’s decision to engage with a particular health service – a key finding in this study. Our research therefore supports ABM in helping to map out the reasons for non-attendance to DSME.
A key limitation is that participants were recruited by phoning eligible people and inviting them to participate. Some individuals who declined the invite to participate held highly negative attitudes towards their type 2 diabetes. For example, some said their type 2 diabetes was shameful, burdensome and that they did not want to talk about it. It is therefore important to be aware that the views of individuals with such attitudes towards their diagnosis may not be fully captured in this study, and that these negative attitudes towards one’s diagnosis may have been a barrier to attendance in themselves.
In summary, the reasons for not attending DSME found in this study are wide-ranging, complex and individualised, providing further support to existing literature on the barriers to DSME attendance. The findings mirrored the constructs in ABM indicating that ABM is a well-supported model to help map out the barriers to DSME attendance. There is no one-size-fits-all solution to increasing attendance. Instead, a more person-centred approach to understanding people’s experience, needs and capabilities is essential to help identify and overcome barriers to attendance. This is in line with the evidence-base that person-centred approaches to health care and promotion are highly effective at overcoming barriers and increasing engagement .