Abstract
Introduction
Diabetes mellitus Type 2 (T2DM) requires a set of life-long, complex self-management strategies that affect both physical and psychosocial aspects of daily life. Risk perception significantly influences individual health behavior choices, 1 including self-management behaviors, and perceived risk correlates with diabetes self-management behaviors. 2 Researchers have posited that poor self-management can be defined as “illness-specific risk taking” 3 due to individual deviations from illness-specific accepted best practices. Wasserman et al 4 posit that adolescents with Type 1 DM may knowingly engage in non-adherent or unhealthy behaviors related to diabetes, in order to meet other social and emotional needs. This emerging framework of diabetes-specific risk-taking behaviors includes themes around routine diabetes management, relationships, substances, healthcare system interactions, and mental health/well-being. 4 Adults living with chronic illness such as diabetes should balance physical, social, and emotional needs throughout the life course; yet little is known about illness-specific risk-taking behavior in adults with T2DM.
Veterans with T2DM present as a unique population for studying self-management and risk-taking behaviors because of the potential influence of sociocultural factors on perceived stress and Veteran health. Veterans face unique challenges and may have different experiences and self-management behaviors compared to non-Veterans.5,6 For example, military structure, eating environments, irregular schedules, stress, and trauma all can affect eating habits.7,8 Military culture is linked closely with military identity, involving rituals and routine, 9 potentially impacting values around stoicism, the warrior identity (including physical strength), 10 and perhaps even tolerance to risk. 11 Importantly, risk-taking has been considered among Veterans suffering from mental health conditions, including PTSD and traumatic brain injury.11,12 Given these factors, it remains unclear whether diabetes-specific risk-taking behaviors, originally studied in adolescents with T1DM, may be applicable to Veterans with T2DM.
To begin to address this gap in the literature, we conducted a secondary analysis of interviews related to diabetes distress among 36 Veterans to learn how diabetes-related risk-taking might intersect with self-management behaviors among Veterans with T2DM. Figure 1 details how we conceptualized risk perceptions in Veterans with T2DM, within the larger literature of risk perceptions. Therefore, this study aimed to assess how Veterans with T2DM describe self-management behaviors and to explore whether a framework of diabetes-specific risk-taking behaviors (originally applied to adolescents with T1DM) is applicable to Veterans with T2DM.
Conceptualization of risk perceptions in Veterans with T2DM.
Methods
Design
This was a descriptive qualitative secondary analysis of interview data from Veterans with T2DM (n = 36) who receive care at a VA Health Care System in the southeastern United States and were participating in a larger, mixed-methods study titled
Data Source
As part of semi-structured interviews focused on diabetes distress conducted in the primary study, 14 Veterans openly shared their experiences managing T2DM. During coding and analysis of these interviews, the study team detected unique and separate descriptions of Veterans’ self-management, both aligned and not aligned with clinical guidelines, prompting this secondary analysis. These interviews, lasting 45 to 60 min, were conducted with 36 Veterans and completed by a trained qualitative analyst. A research assistant obtained informed consent of all participants via telephone prior to any interviews in the primary study. Recordings were completed as permitted by participants. This secondary analysis of qualitative data explored self-management behaviors and diabetes-specific risk-taking behaviors, mentioned by Veterans during discussions about diabetes distress for this primary study.
Guiding Framework
The Summary of Diabetes Self-Care Activities (SDSCA),16,17 ADCES7 Self-Care Behaviors (ADCES7), 18 and Diabetes-Specific Risk-Taking Inventory (DSRI)4,19 guided all study activities; these frameworks were specifically chosen to evaluate T2DM self-management behaviors in the theorized context of risk-taking. The SDSCA is a reliable and valid brief self-report measure for assessing various aspects of diabetes self-management, including diet, exercise, blood glucose testing, foot care, and smoking status. This instrument is used to evaluate the multidimensional aspect of diabetes self-management; however, medications are also critical to diabetes care and is added in the present study. In this study, items from the ADCES7, specifically healthy coping, healthy eating, being active, taking medication, monitoring, reducing risk, and problem solving, are described as “optimal health behaviors,” and behaviors that diverge from the ADCES7 are described as “sub-optimal health behaviors.” Table 1 (Crosswalk for Data Analysis) evidences the close connections between the domains and ADCES7. The framework by Wasserman et al 4 (routine diabetes management, relationships, substances, health care system, and mental health/well-being) was used to identify the applicability of diabetes-specific risk-taking behaviors among Veterans with T2DM.
Crosswalk for Data Analysis.
Data Analysis
This qualitative secondary analysis utilized a deductive a priori template of codes and thematic analysis.20,21 The coding template framework included the 5 regimen areas assessed by the SDSCA16,17 (i.e., diet, exercise, blood-glucose testing, foot care, smoking status) as well as a sixth domain, medication, which was included due to its importance in diabetes management. We coded the presence of optimal health behaviors as indicated by the ADCES7 and coded sub-optimal health behaviors as those that diverged from ADCES7. We then structured the coding through the a priori domains of the SDSCA. We further searched for strategies to support optimal health behaviors once they were coded. Two authors (JRJ, ALL) performed all coding and then compared the results. The remaining authors reviewed the analysis and any discrepancies were resolved through discussion and team consensus. The analysis20,21 was an iterative process that included data condensation and was discussed among the research team at multiple time-points of the analysis. Including the research team as part of the data condensation/analysis process contributed to study dependability. 22 In addition, analyst triangulation further contributed to study credibility by combining multiple team member perspectives to strengthen the analysis and results. 23 To achieve the study aim, we also utilized a framework analysis 24 to explore diabetes-specific risk-taking behaviors in the data.
Results
Veterans described in detail various types of risk-taking associated with their T2DM self-management behaviors. We identified the following themes from this data: (1) diet: constant negotiation can involve purposeful risk-taking; (2) physical activity: intentional, but also avoided despite consequences; (3) blood-glucose monitoring: personal effort of monitoring can override risk-reduction; (4) foot care: preventing complications; (5) smoking: struggles and successes with quitting; and (6) medication: intent to adhere can be undercut by risk-taking and lack of resources. The results indicate that diabetes-specific risk-taking behavior may be an applicable concept to Veterans with T2DM (“I know what I shouldn’t be doing but I still go out and do it” [Participant M]).
Theme 1: Diet: Constant Negotiation Can Involve Purposeful Risk Taking
Self-Management Behaviors
Some Veterans described trying to eat healthier snacks in order to support blood glucose (BG) control. One participant reported that they intentionally do not snack “mindlessly” (Participant A1). Some Veterans shared the ways in which, or approaches by which, they attempt to avoid sweets and sugary foods to keep their T2DM under control, as depicted in Figure 2. Many participants shared that they are conscious about, and work to maintain, a healthy, varied diet; eating “right” (i.e., proper portion control, low salt and sugar consumption) was expressed as a “number one” priority (Participant A1a) and a way to “self-manage” (Participant H). One participant reported working with a Veterans’ Affairs life coach to establish an optimal diet plan.
Veteran approaches to avoid sweet and sugary foods.
Diabetes-Specific Risk Taking
Participants also shared diet self-management choices and behaviors that could be considered sub-optimal. Some described struggling with the financial aspects of diet. For example, one participant reported that she eats “right” when she can “afford to” (Participant G), and another stated, “Sometime[s] I run out of my food a little bit and I have to figure out how I’m gonna get some food cause I pay so many bills” (Participant A1a). One participant expressed that their diet management “falls apart at night” (Participant F). Another described that each day is a “battle of what I can eat and what I can’t eat” (Participant A2a). One participant expressed, “Nothin [
“I’m a cruiser, my wife and I have been on a lot of cruises. . . . And I eat like an elephant. . . . I do not take my tester with me. . . . I don’t even take my insulin with me. Why? Because if it’s gonna kill me it’s gonna do me while I’m gone and having fun” (Participant C1). Multiple Veterans discussed engaging in destructive or risky eating, despite knowing the consequences: “I went on a [cake] binge and . . . just totally dismissed the diabetes like a fool. And I kept eatin’ . . . cakes and it just messed my sugar up and it was there for a while and I didn’t know it and I called the ambulance. And my sugar was 577. They rushed me to the emergency room” (Participant L). Veterans also shared experiencing personal, internal mental distress often related to diet, which interfered with their individual management of diabetes (“And sometimes you just get so frustrated you just say well I’m tired of this . . .. Just being diabetic is, can really play with your mind. And it does create problems [Participant B]). One Veteran shared: “I have been a big failure at managing diabetes. . . . So . . . you end up kind of in your room depressed and hiding candy and fudge and everything else you can hide because you don’t want your family members knowing that you’re depressed and loading yourself up with sugar. . . . You just really fail.” (Participant N). Veterans eloquently express the individual internal negotiations they experience when encountering risky choices related to their diabetes self-management, including the “constant checking, . . . [j]ust being around the wrong food and vibe . . . you have to fight the demon” (Participant E1a).
Theme 2: Physical Activity: Intentional, but Also Avoided Despite Consequences
Self-Management Behaviors
Optimal self-management activities centered on physical activity at work, walking, biking, attending the gym, and calisthenics. Work (either paid labor or jobs around the home) was often described as a source of exercise or activity. Participants described meeting exercise needs by engaging in “labor intensive [work]” (Participant A), being “very active” (Participant B) at their job, or walking around their work facility. Work around one’s home, including “tinkering” (Participant E) outside with a truck or doing yard work, was also viewed as physical activity. Walking was frequently described as a form of exercise by many Veterans: “I love to walk” (Participant D); “[I’m] always walking” (Participant G). Veterans also shared that riding a bicycle, attending a gym, or creating their own calisthenics routine (e.g., “pushups, sit-ups” [Participant J]) were also elements of their physical activity routines.
Diabetes-Specific Risk-Taking
Veterans also shared either not engaging in planned exercise at all (“No exercise at this moment” [Participant I]) or knowingly not engaging in any physical activity outside of work despite knowing that this behavior is “bad” (“That’s the bad thing I don’t have that [much] activity other than what I do at work” [Participant C]). Chronic pain was noted as a particular barrier to physical activity: “Exercising [is] intermittent because, I mean, I’m in pain all the time” (Participant H).
Theme 3: Blood Glucose Monitoring: Personal Effort of Monitoring Can Override Risk-Reduction
Self-Management Behaviors
Participants described various personalized, and often regular, routines involving BG testing (“First thing I do, is check my blood sugar first thing in the morning” [Participant A2b]). Participants also described testing before eating to determine what to eat and the amount of insulin required, as well as before and after meals to assess the effect of food on their BG. Participants described known internal physical sensations that indicated their own BG changes and from which they would judge their need for self-management interventions. For example, one Veteran shared: “How you feel is different throughout the day [so] that you’ll be able to see if something is wrong” (Participant E2).
Diabetes-Specific Risk-Taking
Sub-optimal BG self-management involved not testing according to healthcare providers’ recommendations or guidelines, at times out of frustration, with one participant sharing: “[I’m] fed up with it” (Participant F) and another explaining: “I just don’t do it. . . . I can’t even think of the last time I’ve pricked my fingers” (Participant I1). Resources also impacted BG testing; as one participant explained, “The VA lets me check it [BG] twice a week. They send me enough strips to do it twice a week” (Participant A2). Another participant shared: “Sometimes I don’t test as much as I should because the VA won’t supply the strips” (Participant A2a). In response to high readings, if one Veteran had “anything above 400, [he would] fast for a day or two . . . just to being the glucose readings down” (Participant F). Another Veteran did not check BG regularly because he was “tired” of the process: “I rarely check my diabetes because I get tired of pricking my fingers” (Participant G).
Theme 4: Foot Care: Preventing Complications
Veterans minimally discussed self-management activities involving foot care in this study. Importantly, no specific questions were asked about foot care. While 7 participants discussed self-management related to foot care, all 7 only discussed optimal self-management behaviors, including using foot-cream or indoor footwear, routinely performing self-management on their feet to prevent complications, and checking for numbness to avoid amputations. Two participants described observing their healthcare provider check their feet, after which one participant began checking his own feet, having learned from the observation. As one Veteran expressed, “I take care of my feet . . . ‘cause I don’t want anything to happen to me” (Participant A1a).
Theme 5: Smoking: Struggles and Successes with Quitting
Self-management behaviors involving smoking were discussed in a very limited way by the Veterans in this study; no specific questions were asked about smoking. Only 2 participants discussed smoking at all; one shared that he had stopped smoking and the other shared that he had started smoking again, describing this activity in fairly minor terms despite the risk potential: “And plus I picked up my little habit again . . . My little smoking habit” (Participant E1).
Theme 6: Medication: Intent to Adhere Can Be Undercut by Risk-Taking and Lack of Resources
Self-Management Behaviors
Multiple Veterans described taking medications routinely, as required, or as prescribed. Veterans discussed using insulin, non-insulin injectables, and oral medications. Typical comments included “I make sure I take my medicine every day” (Participant I1). One participant shared that he is working to better adhere to his medication regimen. Reminders utilized to support adherence included phone alarms, timers, and family member involvement.
Diabetes-Specific Risk-Taking
Several Veterans discussed sub-optimal medication self-management behaviors, including taking medication irregularly or outside of recommended time frames, or skipping medication for days (“Between me and you, sometimes I skip a day” [Participant E1]). Veterans sometimes used terms for medication adherence suggestive of a struggle to “control” diabetes (Participant A2). Challenges to adherence included timing conflicts (“I might skip it occasionally because I’m busy” [Participant A1]), chronic pain, the impact of sleep difficulties, or simply forgetting despite reminders. Employment and finances presented challenges; one Veteran related: “I spent most of this pandemic this year unemployed . . . so there were days, or even weeks, I’d go without even taking my medication or my insulin” (Participant A). Diabetes-specific risk-taking behaviors also related to the larger health care system and involved negative interactions with health care team members or care interruptions. Veterans shared that they needed help from providers but either had to wait too long for care, experienced cancellation of appointments (“I can’t see who I need to see” [Participant K]), or felt that the provider was not knowledgeable (“clueless . . . if they ain’t worried, I ain’t worried” [Participant H]). Veterans also felt embarrassed when discussing lab results with their provider (“I feel like . . . I’m explaining why I didn’t do my homework to a teacher” [Participant A]). Multiple Veterans shared that they decided to manage diabetes differently from how their providers recommended (The “nutritionist slip . . . they say you pretty much have to follow . . . Uh-huh. You ain’t got to follow that. You follow your own body” [Participant A1b]).
Discussion
This secondary analysis sought to explore how Veterans perceive and navigate behavioral self-management in the context of a primary study involving conversations about diabetes distress. Qualitative secondary analyses are one tool to uncover evidence beyond a primary study’s initial scope to address aspects not fully explored initially.25,26 The conversations of participants provided detailed insights into their personal T2DM self-management practices and behaviors and the results illustrate diabetes-specific risk-taking associated with various self-management practices. Taken together, these findings suggest that a better understanding of risk-taking or risky behaviors commonly associated with self-management strategies may be an important strategy to improve DM control (see Figure 3). Future work should consider comparing risk-taking among adults with T2DM to current literature on adolescents with T1DM.
Proposed potential relationship.
In our study, the findings indicated that even during specific questioning about diabetes distress, participants revealed personal details and important insights about their own self-management behaviors. These results indicate a novel space where clinicians can use active or engaged listening 27 to find valuable patient information and further highlights specific considerations for practitioners to consider. Existing literature supports this opportunity for information gathering during clinical conversations. Linguistic analysis has evidenced that nurses use small talk to gather additional useful information within otherwise targeted clinical conversations. 28 Other qualitative methods, including conversation or discourse analysis, have also been used to analyze a nurse-patient interaction 29 and virtual interactions among participants, including a diabetes educator. 30 Information gathering can even include online communication, as shown by a qualitative analysis of vlogs used by Veterans to support their self-management of chronic illness. 31 The findings further suggest there may be opportunities for clinicians to listen and offer additional, targeted support if the Veteran/patient desires, and staff can alert the clinician if warranted by the information gathered, especially since the number of topics in a primary care visit are increasing 32 and visits are limited in time. 33
Participants’ interviews also illustrated the complexity and personalization of their T2DM self-management (see Table 2). Veterans shared individual insights and personal stories about their T2DM self-management routines, successes, and challenges, and demonstrated a strong knowledge base. Notably, all participants are closely affiliated with a regional VA medical center and thus have consistent, if sometimes strictly regulated, access to healthcare providers, medications, and supplies. Overall, the Veterans in this study possessed a good understanding of managing their T2DM and regularly utilized healthcare services with the VA and in the community; yet despite this, many in our sample described sub-optimal (or “risk-taking”) self-management health behaviors that deviated from recommended diabetes management practices, that health care professionals characterize as potentially placing the Veteran at greater risk for poor outcomes. Without a better understanding of the nature of diabetes-specific risk-taking behavior among Veterans, it is difficult to prepare clinicians to engage in shared decision-making with Veterans to enhance self-management practices and ultimately achieve better disease control.
Research Findings and Implications.
As such, the findings also indicate that the diabetes-specific risk-taking concepts as detailed by Wasserman et al 4 are potentially applicable to Veterans with T2DM, in particular when balancing the tension between physical health and psychological-emotional needs. Additional literature further suggests that similar results may also be present in non-Veteran adult populations. For example, a study in Israel found that risk-seeking (measured through a task used to assess risk posture) was associated with lower levels of T2DM self-management. 34 This area of scholarship would benefit from future research directly investigating risk-taking behaviors. Other distinctive and adult-focused internal tensions evident in the results, for example competing demands between multiple chronic illnesses, may also lead to greater risk-taking behavior. Scholarship suggests that behaviors and biographies carry into an individual’s later life with regards to chronic illness, 4 making Veterans with T2DM a potential new population to consider as impacted by diabetes-specific risk-taking. In the future, clinicians may hear these types of comments, but may not be equipped to respond to these admissions in a manner that preserves the relationship. The motivation for future work is to understand the impact of risk perception and risk-taking behaviors in the context of both diabetes distress and self-management, and future work will create a model to successfully respond to the needs of Veterans. Already existing scholarship regarding how health care professional do or do not address risky behavior, including but not limited to how nurses can use message tailoring and message framing with their patients during education, 35 can potentially be explored in this proposed, more focused, setting.
Limitations
This work has some limitations that should be noted. First, Veterans may not bring up self-management behaviors unless they are specifically asked and/or they have a trusting relationship with the interviewer. However, this was a first step in considering the applicability of risk-taking among Veterans with T2DM and future work will intentionally target risk perceptions and risk taking. Second, this study was conducted among Veterans very engaged with healthcare services. Future work will be needed including Veterans in less complex medical centers and in those who receive care in the community. Third, the data corpus had limited information on foot care and smoking as these topics were not directly asked in the interview guide. Yet, the absence of discussion of these 2 behaviors does not imply that these topics did not occur in the Veterans’ experiences.
Conclusions
Disease-specific risk-taking behavior may be an important lever to understand how best to help individuals with T2DM achieve better outcomes. This study highlighted Veteran T2DM self-management behaviors discussed in the context of conversations concerning diabetes distress and can support the development of tailored interventions and diabetes care designed to address individual self-management behaviors and related burdens. Future interventions should recognize the importance of individual personal choices and ongoing constant internal negotiations in self-management, which are essential aspects of the broader context of behavioral self-management in individuals with T2DM. This study further explored the relevance of diabetes-specific risk-taking concepts to Veterans with T2DM and affirmatively suggests it is a potential future productive area of study. If the goal is for the patient to take fewer risks, providers need to better understand the impact of risk-taking on Veteran self-management.
Footnotes
ORCID iDs
