Abstract
Introduction: Type 2 Diabetes Mellitus (T2DM) is one of the most severe and common chronic conditions globally. Yet T2DM is primarily a self-managed disease, which many people with T2DM find challenging to undertake. This puts them at high risk of developing diabetes-related complications. In Fiji, T2DM is one of the leading causes of death and disability, particularly amongst I-Taukei Fijians, the indigenous peoples. Self-management includes eating a healthy diet, regular physical activity, footcare, daily monitoring of blood sugar levels, medication use, and engagement with health services. A systematic review, conducted as part of this thesis, identified a range of factors that could enhance T2DM self-management, including the patient's individual drive, social capital, level of knowledge of diabetes self-management, level of support provided and its affordability, and the accessibility and adequacy of health care services.
Currently, most studies of T2DM self-management use self-report methods, which run the risk of recall bias and social desirability bias. Wearable cameras provide a new means to objectively study the world. This thesis presents research using Diabetes Cam, a new methodology developed for this thesis that uses wearable cameras to study T2DM self-management. This research aimed to study T2DM self-management and identify the barriers and facilitators to self-management faced by I-Taukei living with T2DM in Fiji.
Methods: A strategic sample of 30 I-Taukei adults with T2DM participated in this mixed-methods study, Diabetes Cam Fiji. They were from the four health divisions in Fiji. Participants wore an automated camera (Autographer Qstarz BT-Q1300ST) for four days on a lanyard around their necks during waking hours. The camera took photographs every 7 seconds using a 136° lens. Participants recorded 345,000 high-quality, codable images (approximately 11,500 per participant), averaging 6 hours a day across a range of settings. Photo-elicitation interviews were conducted with participants using images as prompts. The researcher's observations provided further context about the home environment. Data were collected from October 2021 to May 2022. Images were manually coded against coding schedules based on previous research or T2DM guidelines. Interviews were thematically analysed, and observations were descriptively analysed. Analysis included food consumption, healthcare access and utilization, and footcare self-management.
Results: I-Taukei with T2DM are struggling to eat a healthy diet. More than half of the food and drinks consumed were unhealthy, despite participants knowing the need for a healthy diet. This was due to the cost of healthy food, reliance on others, and the availability of unhealthy food. Participants received unrealistic advice about diet from health professionals, and their coping strategies were largely ineffective.
All participants discussed their recent healthcare experiences; eight participants visited healthcare services whilst wearing a camera. Four key themes were identified from the interviews, supported by images and observations: (i) barriers to access to healthcare clinics, (ii) inadequate resources for diabetes self-management, (iii) limited diabetes self-management health education, and (iv) key facilitators to healthcare access and utilisation.
While all participants reported performing footcare, most limited it to checking for cuts and wounds. Those with foot complications, such as amputations, often leave employment. Key barriers included the lack of preventive health services and support; poor resourcing and accessibility of dressing supplies, blood sugar testing kits, and mobility aids; and the warm climate, which hindered the wearing of closed shoes. Access to appropriate housing and transportation were also a key barrier for those with amputations. Facilitators included family and community support.
Conclusions: This research illustrates the profound impact of T2DM on the lives of I-Taukei in Fiji. It also highlights the struggle many face in managing their condition despite the motivation to do so. I-Taukei would benefit from returning to a traditional diet, replacing the largely unhealthy non-traditional foods they currently consume. This requires support from across the government, including fiscal, trade, and education policies. Numerous systemic and equity issues limit access to and utilisation of health care, creating barriers and missed opportunities from prevention to the treatment of complications. Addressing this key right to health issue and improving diabetes management in Fiji requires urgent and sustained focus, increased resourcing, and the embedding of a patient-centered approach throughout the system. This study suggests that I-Taukei patients recognise the need for self-managed footcare and are largely motivated to do so. However, there is a lack of health education, and the health service lacks the resources and trained staff to meet people's needs. The underfunded and under-resourced health system is a major contributor. Health promotion approaches to diabetes footcare self-management in Fiji could significantly improve the lives of people living with diabetes and reduce the risk of complications and amputation.
Improving T2DM self-management in Fiji requires a sustained systems focus on improving the food supply and an urgent overhaul of the health care system. Intersectoral collaboration between funders/policymakers, healthcare providers, communities, and patients will be key. Donor countries and the WHO need to urgently consider the necessary support to help Fiji manage this increasingly challenging public health issue. The Diabetes Cam methodology and the findings of this research may be of value in other countries struggling with the T2DM crisis.