What are the self-management experiences of the elderly with diabetes? A systematic review of qualitative research

Table 1 Summary of studies and reported study results

Ref.	Purpose	Method	Study population/setting	Data collection	Data analysis	Major findings
Pamungkas et al[35], 2017, Brazil	Identify categories of self-care among older adults with diabetes, considering their physical, mental and spiritual dimensions	Qualitative	n = 13; Aged ≥ 60; With diabetes		Method	Difficulties of self-control while living with diabetes Self-care in living with diabetes and raising self-esteem; Optimism and perseverance in diabetes care; Living peacefully with diabetes; The burden of diabetes in life; Self-care always to live longer and better; Understanding the importance of coexistence with the family; Self-care with the body and the mind; Conscious carelessness; Living happily all of the time
Joo and Lee[32], 2016, United States	Explore barriers to and facilitators of diabetes Self-management among first-generation Korean–American elderly immigrants with type 2 diabetes	Qualitative	n = 18; Aged ≥ 65; 12 males; 11 females; Diagnosed with type 2 diabetes for at least a year	(1) Focus group interview; and (2) Individual interview	Content-based analysis	High cost of type 2 diabetes care; Language issues; Loss of self-control; Memory loss; Limited access to healthcare resources; Time; Seeking information; Family and peer support
Song et al[31], 2010, Korea	Identify barriers to and facilitators of self-management Adherence in Korean older adults with type 2 diabetes mellitus	Qualitative	n = 24; Aged ≥ 65; 10 males; 14 females; Had been diagnosed with diabetes 12.8 yr before	Focus group interview	Interpretive meth o	Aging-related physical and psychological changes Restrictions related to specific cultural factors; Lack of self-discipline; Poor understanding of self-management; Knowing the benefits of self-management and having a system to reinforce it; Being the master of oneself by reshaping historical life habits and family support
Li et al[27], 2013, Singapore	Describe, through qualitative methods, the experiences and ways of coping of older Singaporean Chinese women with type 2 diabetes	Qualitative	n = 10; Aged 60–69; 10 females diagnosed with type 2 diabetes	Semi-structured interviews	Thematic analysis	Living with diabetes; Coping with diabetes; Caring for self
Bustillos and Sharkey[36], 2020, United States	To study the experiences and challenges of type 2 diabetesSelf-management among homebound older adults who regularly receive home-delivered meals and services	Qualitative	n = 31; Aged ≥ 65; Eight males; 23 females; Diagnosed with type 2 diabetes	Semi-structured interviews	Thematic analysis	Perceived seriousness of diabetes relative to other health problems; Perceived self-management; Perceived barriers to self-management: Physical activity; Perceived barriers to self-management: Economic
Beverly et al[28], 2014, United States	Explore older adults’ values and preferences regarding type 2 diabetes care	Qualitative	n = 25; Aged ≥ 60; 11 males; 14 females diagnosed with type 2 diabetes by a doctor at least 1 yr before the study	Focus groups interview	Thematic analysis	Respect and responsiveness to individual values and preferences can foster collaboration in physician–patient treatment relationship and help older adults feel confident that their treatment matches the values and preferences they deem important
George and Thomas[30], 2010, United States	Elucidate experiences and perceptions of individuals with diabetes with regard to self-management, as narrated by older people diagnosed with insulin-dependent diabetes living in a rural area	Qualitative	n = 10; Aged = 65–85; Diagnosed with type 2 diabetes	Unstructured interviews	Phenomenology analysis	Your body will let you know; I thought I was fine, but I wasn’t; The only way out is to die; You just go on
Washington and Wang-Letzkus[37], 2009, United States	Identify risk factors related to lifestyle, attitudes, and health beliefs, and the influence to self-care practices of Chinese American immigrants	Qualitative	n = 13; Aged ≥ 65; Seven males; Six females; Diagnosed with type 2 diabetes at least one year before the study	Focus group interview	Thematic analysis	Positive perceptions and optimistic attitudes will optimise diabetes self-care outcomes
Carolan-Olah and Cassar[33], 2018	Experience of living with diabetes and factors that facilitated or inhibited access to diabetes services	Qualitative	n = 13; Eight males; Five females; Aged ≥ 60; Diagnosed with type 2 diabetes	Focus group interview		The value of health; The impact of diabetes; Making changes; Managing diabetes; Access to information and services
Tang et al[29], 2015, China	To understand the self-management ability of elderly people with diabetes in the rural areas of Ji’an	Qualitative	n = 13; Aged ≥ 60; 8 males; 5 females; Diagnosed with type 2 diabetes	Semi-structured interviews	Analysis	Lack of related knowledge of diabetes; Unable to change habits; Influence of family social support and health condition

Table 2 Critical appraisal skills program score and GRADE-confidence in the evidence from reviews of qualitative research relevance ratings

Ref.	1-Was there a clear statement of the aims of the research?	2-Is a qualitative methodology appropriate?	3-Was the research design appropriately addresses the aims of the research?	4-Was the recruitment strategy appropriate to the aims of the research?	5-Were data collected in a way that addresses the research issue?	6-Was the relationship between researcher and participants been considered?	7-Were ethical issues considered?	8-Was the data analysis sufficiently rigorous?	9-Was the statement of findings clear?	10-How valuable is the research?	Score	Relevance
Pamungkas et al[35], 2017	Yes	Yes	Yes	Can’t tell	Yes	No	Yes	Yes	Yes	Yes	8.5	I
Joo and Lee[32], 2016	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	9	R
Song et al[31], 2010	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	9	R
Li et al[27], 2013	Yes	Yes	Yes	Yes	Yes	Can’t tell	Yes	Yes	Yes	Yes	9.5	P
Bustillos and Sharkey[36], 2020	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	9	R
Beverly et al[28], 2014	Yes	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes	7	P
George and Thomas[30], 2010	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	9	R
Washington and Wang-Letzkus[37], 2009	Yes	Yes	Yes	Can’t tell	Yes	No	No	No	Yes	Yes	6.5	P
Carolan-Olah and Cassar[33], 2018	Yes	Yes	Yes	Can’t tell	Yes	Yes	Yes	Yes	Yes	Yes	9.5	P
Tang et al[29], 2015	Yes	Yes	Yes	Can’t tell	Yes	No	No	Yes	Yes	Yes	7.5	R

GRADE-confidence in the evidence from reviews of qualitative research relevance component: I: Indirect relevance; P: Partial relevance; R: Relevant; U: Uncertain relevance.

Table 3 Confidence in review findings: GRADE-confidence in the evidence from reviews of qualitative research assessment

Summary of review findings	Studies contributing to the review findings	Methodological limitations	Relevance	Coherence	Adequacy	Assessment of confidence in the evidence	Explanation of CERQual assessment
Need for knowledge about diabetes care	Eight Studies[27,29-33,35,36]	Minor methodological limitations (six no concerns; two minor concerns).	Minor concerns (one indirect; two partial; five relevant)	Very minor concerns (data very consistent within and across studies)	No concerns (eight studies that offered rich datal)	High confidence	Finding graded as high because of the range of studies, richness of data, and relative consistency of the finding in relation to the review question
Support system	Eight studies[27-29,31-33,35,36]	Minor methodological limitations (six no concerns; two minor concerns)	Minor concerns (one indirect, three partial, four relevant)	Minor concerns (data very consistent within and across studies)	Minor concerns (Eight studies that together offered data to the two sub-themes)	Moderate confidence	Finding graded as high because of the range of studies, the richness of the data and the relative consistency of the finding in relation to the review question
Function decline	Seven studies[27,30-33,36,37]	Minor methodological limitations (six no concerns; one moderate concerns)	Minor concerns (three partial; four relevant)	Minor concerns (data consistent within and across studies)	Minor concerns (seven studies that offered moderately rich data)	Moderate confidence	This finding was graded as moderate confidence because of minor concerns regarding methodological limitations, relevance, coherence, and adequacy
Attitudes toward diabetes	Six Studies[27,30,31,35-37]	Minor methodological limitations (five no concerns; one with moderate concerns)	Moderate concerns (one indirect; two partial; three relevant)	Minor concerns (data consistent within and across studies)	Minor concerns (six studies that offered moderately rich data)	Moderate confidence	This finding was graded as moderate confidence because of moderate methodological limitations and minor concerns regarding relevance, coherence, and adequacy
Healthy lifestyle challenges	Ten studies[27-37]	Minor methodological limitations (seven with no concerns; two minor concerns; one with moderate concerns)	Minor concerns (one indirect; four partial; five relevant)	Minor concerns (data consistent within and across studies)	No concerns (eight studies that offered rich data)	High confidence	This finding was graded as moderate confidence because of moderate methodological limitations and minor concerns regarding relevance and coherence

CERQual: Confidence in the Evidence from Reviews of Qualitative research.