Developing a conceptual framework for type 2 diabetes care and self-management using a qualitative evaluation from India

Abstract

Type 2 Diabetes (T2D) is a major public health concern in India, with suboptimal outcomes despite established guidelines and improved healthcare facilities. Understanding the barriers and facilitators influencing diabetes care and self-management is essential for effective context- specific intervention design. We conducted semi-structured, in-depth interviews in July 2023 with 18 adults (aged 35–65) with T2D from low, middle, and high socioeconomic groups in Delhi, India, using purposive sampling. The interview guide explored demographics, health awareness, and barriers and facilitators to behavior change and healthcare use. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis (Braun and Clarke). Framework development was informed by grounded theory principles. Rigor was ensured through independent coding, triangulation, and adherence to COREQ guidelines. Three interrelated themes emerged: (1) personal attributes (self-experience and social influences), (2) healthcare access (availability, affordability and provider interaction) and (3) enabling factors (financial resources, knowledge, and education). Key barriers included poor risk perception, fear of medication dependence, inconsistent provider communication, and out-of-pocket costs compounded by overcrowded facilities and limited access to reliable information. Key facilitators included family support, positive provider engagement, and access to free/subsidized medicines, tests, and counseling. These findings were integrated into the ‘Determinants of Diabetes Care and its Management (DDM)’ framework, which highlights the complex interplay of individual, socio-cultural, and health system factors influencing care-seeking and adherence. This study provides a comprehensive understanding of the interconnected individual, social and systemic determinants affecting diabetes care in India. The proposed DDM framework provides actionable insights for designing patient-centered interventions, strengthening provider communication and improving equitable access to care, particularly in resource-constrained settings, with implications for program implementation and policy. Trial registration CTRI/2023/10/058452 dated 7/July/2023.