An Exploration of Self-Care Practice and Self-Care Support of Patients with Type 2 Diabetes in Malaysia A thesis submitted to The University of Manchester for the degree of Doctor of Philosophy in the Faculty of Medical and Human Sciences 2015 Sanisah Saidi School of Nursing, Midwifery and Social Work TABLE OF CONTENTS TABLE OF CONTENTS ............................................................................................................. 2 List of Tables ............................................................................................................................... 8 List of Figures .............................................................................................................................. 9 List of Appendices ..................................................................................................................... 10 Abstract ...................................................................................................................................... 11 Declaration ................................................................................................................................. 12 Copyright statement ................................................................................................................... 12 Acknowledgement ..................................................................................................................... 13 Background to the author ........................................................................................................... 14 Organisation of the thesis ........................................................................................................... 15 Chapter 1 ...................................................................................................................................... 16 Study Background ...................................................................................................................... 16 1.1 Introduction ...................................................................................................................... 16 1.2 Background to the research problem ............................................................................... 16 1.3 Self-care in type 2 diabetes .............................................................................................. 18 1.4 Overview of study context ............................................................................................... 20 1.4.1 Overview of Malaysian healthcare system ........................................................... 22 1.5 Summary .......................................................................................................................... 23 Chapter 2 ...................................................................................................................................... 24 Literature Review....................................................................................................................... 24 2.1 Introduction ...................................................................................................................... 24 2.2 Literature search strategies............................................................................................... 24 2.2.1 Research objectives for literature review .................................................................. 24 2.2.2 Research questions for literature review ................................................................... 25 2.2.3 Search strategies ........................................................................................................ 25 2.3 Findings of the search ...................................................................................................... 27 2.3.1 Assessment of the reviewed studies .......................................................................... 28 2.3.1.1 Overall weight of evidence ................................................................................ 30 2.4 Synthesis of study findings .............................................................................................. 32 2.4.1 Level of adherence to self-care of patients with type 2 diabetes .............................. 33 2 2.4.2 Experience of patients with type 2 diabetes and factors influencing engagement with self-care .............................................................................................................................. 36 2.4.2.1 Invisible disease and lack of acceptance ............................................................ 36 2.4.2.2 Challenges of integrating self-care in to daily life ............................................. 39 2.4.2.3 Facilitators to self-care ....................................................................................... 41 2.4.3 Provision of self-care support ................................................................................... 44 2.4.3.1 Importance of support from HCPs ..................................................................... 44 2.4.3.2 Effectiveness of self-care support provision ...................................................... 48 2.5 Theoretical underpinned the self-care support interventions ........................................... 52 2.6 Summary of literature review and justification of current study ..................................... 54 Chapter 3 ...................................................................................................................................... 56 The Research Paradigm and Methodology ................................................................................ 56 3.1 Introduction ...................................................................................................................... 56 3.2 Research aims and objectives .......................................................................................... 56 3.2.1 Research aims ........................................................................................................... 57 3.2.2 Research questions .................................................................................................... 57 3.2.3 Research objectives ................................................................................................... 57 3.3 Principles underpinning the study methodology .............................................................. 58 3.3.1 Qualitative methodology ........................................................................................... 61 3.4 Underpinning philosophy: Pragmatism ........................................................................... 62 3.5 Summary .......................................................................................................................... 63 Chapter 4 ...................................................................................................................................... 64 Case Study Design ..................................................................................................................... 64 4.1 Introduction ...................................................................................................................... 64 4.2. Case study research ......................................................................................................... 64 4.2.1 Definition a case study .............................................................................................. 65 4.2.2 Propositions in a case study ...................................................................................... 68 4.3 Type of case study design ................................................................................................ 69 4.5 Defining the ‘case’ ........................................................................................................... 72 4.6 Description of case study settings .................................................................................... 74 4.6.1 Case study site one .................................................................................................... 76 4.6.2 Case study site two .................................................................................................... 78 4.6.3 Case study site three .................................................................................................. 79 4.7 Summary .......................................................................................................................... 82 3 Chapter 5 ...................................................................................................................................... 83 Research Methods ...................................................................................................................... 83 5.1 Introduction ...................................................................................................................... 83 5.2 Identifying the data source ............................................................................................... 83 5.3 Process of gaining access ................................................................................................. 84 5.4 Sampling and recruitment of participants ........................................................................ 86 5.4.1 Sampling and recruitment of HCPs .......................................................................... 87 5.4.2 Sampling and recruitment of patients with type 2 diabetes