Received: 22 February 2022  | Revised: 10 March 2023  | Accepted: 5 May 2023
DOI: 10.1002/nop2.1825  
R E S E A R C H  A R T I C L E
Narratives of type 2 diabetes mellitus patients regarding 
the influence of social issues on diabetes self- management: 
Implications for patient care
Kwadwo Ameyaw Korsah1 |   Joana Agyeman-Y eboah2,3
1School of Nursing and Midwifery, 
University of Ghana, Accra, Ghana Abstract
2International Maritime Hospital, Tema, Aim: To explore the perspectives of individuals living with type 2 diabetes mellitus 
Ghana
on the influence of social factors on diabetes self- management in Ghanaian context.
3Knutsford University College, Accra, 
Ghana Design: Hermeneutic phenomenological approach to qualitative research was used.
Method: A semi-s tructured interview guide was used to collect data from 27 par-
Correspondence
Joana Agyeman- Yeboah, International ticipants who were newly diagnosed with type 2 diabetes. Analysis of data was car-
Maritime Hospital, Tema, Ghana and ried out by using content analysis approach. One main theme with five subthemes 
Knutsford University College, Accra, 
Ghana. emerged.
Email: joanaagyemanyeboah@outlook.com Results: Participants experienced social stigma due to the changes in their physical 
appearance. Mandatory isolation was created by participants in order to manage 
the diabetes. The financial status of the participants was affected by the diabetes 
self- management. Differing from the social issues, the overall participants' responses 
to experiences living with type 2 diabetes mellitus culminated with psychological or 
emotional hassles, and therefore, patients resorting to alcohol consumption to deal 
with diabetes related stress, fears, anxiety, apprehension and pain among others.
K E Y W O R D S
diabetes mellitus, management, social
1  |  INTRODUC TION the body turns food into energy (Centre for Disease Control and 
Prevention, 2021). Diabetes mellitus occurs when the body cannot 
Diabetes is a global health issues and its impact on the wellbeing of produce enough insulin or cannot respond appropriately to insu-
mankind cannot be over emphasized. The number of persons with di- lin (Healthy people, 2020). Type 2 diabetes mellitus is one of the 
abetes mellitus has almost increase fourfold since 1980. Prevalence forms of diabetes mellitus aside the type 1 and gestational diabetes. 
is increasing globally, predominantly in low- and middle-i ncome Type 2 diabetes mellitus results from a combination of resistance 
countries (World Health Organization [WHO], 2021). In Ghana, it is to the action of insulin and insufficient insulin production (Healthy 
estimated that diabetes mellitus affects 6.3% of the Ghanaian pop- people, 2020). More than 95% of people with diabetes have type 2 
ulation with type 2 diabetes accounting for 90%– 95% of all cases of diabetes mellitus (WHO, 2021). Diabetes mellitus has a devastating 
diabetes (WHO, 2020). It is a long-l asting disease that affect how effect on the individual and can damage the heart, blood vessels, 
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in 
any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2023 The Authors. Nursing Open published by John Wiley & Sons Ltd.
Nursing Open. 2023;00:1–8.  wileyonlinelibrary.com/journal/nop2  | 1
2  |    KORSAH and AGYEMAN-­YEBOAH
eyes, kidneys and nerves (WHO, 2021). Diabetes mellitus of all types of public parks for exercises and social support in general to mention 
can lead to complications in many parts of the body and increase the a few. This research is situated particularly in the areas of social in-
risk of dying prematurely (WHO, 2020). equalities and social stigma, and diabetes- distress related to diabe-
tes care in the context of Ghana, where patients and their healthcare 
providers encounter unique challenges in self- care and management 
2  |  BACKGROUND of diabetes mellitus. For example, in Ghana individuals living with di-
abetes mellitus encounter challenges including high cost of treatment 
The management protocol of type 2 diabetes mellitus includes of the condition and shortage of medications and stigmatization, and 
daily oral medications or insulin injections, regular blood sugar test- limited access to health resources in general, to mention a few. There 
ing, frequent exercises and being selective in terms of food intake is inadequate number of skilled healthcare staff especially in the rural 
(International Diabetes Federation (IDF), 2018). It has been noted areas to take proper care of persons living with chronic diseases such 
that social and economic issues impact health in general and have as diabetes mellitus. In addition, health system challenges such as the 
been identified as statistically significant factors, which influence di- national health insurance scheme in Ghana does not function appro-
abetes outcomes in particular among persons living with the condi- priately to cushion patients who have contributed to it, due to poor 
tion (Harwood et al., 2013; Solar & Irwin, 2010; Walker et al., 2014). management. The healthcare providers also face similar challenges, 
Social determinants of health are the socio- economic conditions, which centers around patient care barriers such as limited resources 
which affect the health of persons and communities in general and availability of equipment needed for adequate care of the condi-
(Raphael, 2004). The literature mostly centres on the biomedical tion. Staff are demoralized by the management's unwillingness to sup-
care, lifestyle modification including diet, regular exercises, blood port them for innovative changes to patient care, increased burden of 
glucose monitoring and some aspects of psychological issues such patient load without corresponding remunerations, and inappropriate 
as anxiety and depression among individuals living with diabetes cultural beliefs of patients, which militate against patient care. For 
mellitus (Williamson et al., 2004), with diminutive consideration or example, individuals living with diabetes tend to ignore health profes-
attention given to the part played by social determinants of health sionals' advice due to patients' poor beliefs and perceptions, which in 
in the prevention and control in addition to the management and most cases result in poor patient and disease outcomes. It was on this 
treatment of diabetes mellitus (Pilkington et al., 2011). It has also basis that the researchers set off to explore the perspectives of indi-
been noted that social issues are connected with chronic condi- viduals living with type 2 diabetes mellitus on the influence of social 
tions as some of them serve as barriers in managing these diseases factors on diabetes self- management in Ghanaian context, in order to 
(Blas et al., 2012; Raphael et al., 2010; Touma & Pannain, 2011). The find ways to improve the lives of the affected individuals in a holistic 
idea of social issues in health care appears to be associated with approach. The research question, therefore, is what are the influences 
health determinants framework (Dahlgren & Whitehead, 1993) as of social issues on diabetes mellitus self- management?
it is based on individuals or group of individuals, in addition to fac-
tors surrounding them. Persons are at the focal point of this layered 
framework who are impacted by their own environment and actions 3  |  METHODS
(Dahlgren & Whitehead, 1991), as demonstrated by Dahlgren and 
Whitehead (1993) who show the relationships between the person, 3.1  |  Study design
disease and environment (WHO, 2011; Jack et al., 2012).
From the authors observation as professional nurses' with over The investigation employed hermeneutic phenomenological ap-
20 years' experience in clinical nursing practice, it has been noted that, proach to qualitative research for the current study, which dem-
our current healthcare services for individuals with diabetes mellitus onstrates that individuals cannot be disconnected from the world, 
centres mainly on organizing and conducting review clinics and meet- which seems to explain the stand of the research investigators who 
ing them on regular basis to deliver clinical care. Conversely, social could not separate themselves from the research participants in this 
issues confronting the affected persons are given limited attention. study (Kafle, 2013; Reiners, 2012). The theoretical orientation upon 
It is important to recognize that social perspectives around the care which this study depends in terms of hermeneutic phenomenology, 
of patients with diabetes mellitus are worth noting as diabetes mel- centres on the description of personal experiences of the individu-
litus is considered a chronic disease condition (Silva et al., 2018). In als living with diabetes mellitus through understanding and inter-
this sense it requires extensive behavioural changes in the affected pretation of their experiences (Manen, 2014). These reflect on the 
individuals in order to adhere to its treatment in general. Social issues basic assumptions of hermeneutic phenomenology, which indicates 
are considered very essential and key factors for performing self- that humans seek meaning in their lives and that there are several 
care and management among persons living with diabetes mellitus realities in socially constructed meanings from individuals' lived 
(WHO, 2021). In other words, social issues may affect disease con- experiences (Manen, 2014). Thus, hermeneutic phenomenology 
trol and outcome among individuals with diabetes mellitus. Examples focuses on the idea that individuals make meaning of lived experi-
of these factors may include the patient's income level, level of ed- ences (Gadamer, 1997; Kafle, 2013). This study employed 32 COREQ 
ucation, access to health care, access to nutritious diet, availability checklist for qualitative research developed by (Tong et al., 2007).
 20541058, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/nop2.1825 by University of Ghana - Accra, Wiley Online Library on [15/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
KORSAH and AGYEMAN-Y­ EBOAH     |  3
3.2  |  Sample and sampling approach participants questions such as “Tell me about how social factors such 
as your income level, stigma from people, and fear about the disease 
In this study 54 patients, newly diagnosed with type 2 diabetes mel- have affected the treatment of your condition?” were asked. In ad-
litus were invited to take part in this research, but 42 of them re- dition, probes were asked for expansion and clarification of their re-
sponded to the invitation letters, which were sent out. The names sponses. These helped to expand on responses, which were unclear 
of the research participants were obtained from the diabetic clinic to the researchers. Each interview lasted between 45 min to 1 h, ei-
attendance register. The study was opened to patients with type 2 ther in the local Twi language or English. Data collected in the Twi 
diabetes mellitus who were newly diagnosed within 3 months at the language were later translated into English language. Data collection 
hospital. The study recruited persons diagnosed with type 2 diabe- occurred between August and October 2009 at a hospital in Ghana. 
tes mellitus within 3 months. This ensured that individuals diagnosed Twenty- four of the interviews took place in the hospital where the 
within this time frame would easily recollect their experiences living researcher was allocated an office purposely for this research. The 
with the condition, as such experiences would still be fresh in their remaining three interviews were conducted in the homes of the re-
memories. Also being newly diagnosed patients with diabetes mel- search participants with their authorization. In all data saturation 
litus, it was imperative to find out their challenges at the initial stage occurred at the 27th interview, when it was observed that no new 
of the condition in order to offer them the needed support such as information was forthcoming from the research participants (Fusch 
counselling, social support and financial support among others, for & Ness, 2015). Data collection and analysis proceeded simultane-
them to come to terms with the condition at the primary stage of ously. This was done with the aim to ensure that pieces of informa-
the illness. The context for this research in terms of how the care of tion or findings, which emerged from the data analysis shaped the 
patients newly diagnosed with diabetes mellitus occur focused on ensuing sampling and data collection.
the fact upon diagnosis and commencement of treatment. Most pa-
tients are confronted with some challenges such as limited income, 
stigmatization by the public and even at the family level, emotional 3.4  |  Data analysis
distress related to the diagnosis of a debilitating condition and so-
cial isolation for fear of being stigmatized. These social issues affect Analysis of data was carried out by using content analysis approach 
negatively the self- care and general management of individuals who by (Creswell & Creswell, 2018), which was done simultaneously 
are newly diagnosed with diabetes mellitus. with data collection. Recorded data from the research participants 
was transcribed verbatim and printouts were read several times to 
acquire meanings emerging from them. The meanings were then 
3.3  |  Data collection generated to form the research theme, out of which the subthemes 
were identified (Mayan, 2009). The lead author carried out inde-
Data was collected by employing a semi- structured interview guide, pendent data analysis of all the audio-r ecorded interviews in this 
which allowed the researchers to ask open ended questions to guar- study to ensure uniformity of the processes involved. However, the 
antee the conversation with the participants to centre on the key second author was given the opportunity to conduct the second au-
subject related to the influence of social factors on diabetes mel- tonomous data analysis to authenticate, which was done by the lead 
litus self- management (Stuckey, 2013). To ensure consistency of author. This was done to compare and contrast the findings to settle 
data collection, the lead author conducted all the audio- recorded on the mutually suitable research outcomes. The research partici-
interviews. This was to ensure that specific common words and sen- pants were engaged for a prolonged period of time during interviews 
tences were used for participants' understanding in both English and to ensure that questions, which needed clarification were asked in 
Twi languages, which were employed for all interviews. This was to a form of probing. Additionally, piloting of the interview guide was 
avoid variations in their meanings to the research participants, which done using two family relatives of one of the researchers who inci-
could also affect meanings during analysis of data. Back translation dentally had type 2 diabetes mellitus.
of interviews from English to Twi was also done by a colleague re-
searcher to ensure consistency and accuracy as part of strategies 
to guarantee trustworthiness. Additionally, to ensure methodologi- 3.5  |  Ethics
cal rigour, the research participants were interviewed extensively in 
order to get detailed information on the influence of social factors Ethical and scientific approval for the study was obtained 
on diabetes self- management from their point of view. The semi- (REDACTED). Permission was given by the local Diabetes Patients' 
structure interview was composed of two main parts. These were Association to interview its members who agreed to be part of the 
part A and B. Part A of the interview guide was intended to col- study. In this research, some of the ethical concerns that were taken 
lect data on socio-d emographic information. Some of the question, into account were anonymity, confidentiality and informed consent 
which were asked in the part B included “In what ways do you think among others. For instance, written informed consent was obtained 
the management of your condition is affected?”. In some specific willingly from each of the research participants. In addition, pseu-
situations when responses were not forthcoming from the research donyms were given to research participants to obscure their real 
 20541058, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/nop2.1825 by University of Ghana - Accra, Wiley Online Library on [15/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
4  |    KORSAH and AGYEMAN-­YEBOAH
identity in this research. In the same vein, the biographic data of to have been abandoned and blamed by family members and com-
the research participants was detached from the research data to munity members as having AIDS, which is perceived by most peo-
circumvent any linkages between them. ple as deadly and without cure, although it can be managed. Hence 
nobody would want to be associated with a hopeless condition. A 
participant narrated her story this way:
4  |  RESULTS
I have reduced in weight so people accuse me of hav-
The interviews were conducted among 27 patients newly diagnosed ing AIDS. The doctor at the hospital told me that I 
with type 2 diabetes mellitus. Their ages ranged between 38 and have diabetes but because of weight loss individuals 
63 years. In all, there were 12 females and 15 males. Twenty-s ix of are stigmatizing me with a different condition, which 
the participants were affiliated with the Christian religious group is very deadly. 
whereas only one participant was a Muslim. In terms of employment, (P25)
all the 27 participants were employed. Fifteen of the participants 
had attained basic education, seven with secondary education, two The stigmatization and social rejection experienced by the partic-
were professional nurses, one professional teacher and two partici- ipants made them felt troubled. Another participant who felt rejected 
pants had no education background. by the community recounted her experiences below:
One main theme with five subthemes emerged from the data 
analysis. When I am moving around, individuals just gaze at me 
as if there is something wrong with me. Probably, they 
have not seen someone with weight loss before. I am 
4.1  |  The Main theme: Social experiences with pretty disturbed because I feel rejected and unhappy 
diabetes mellitus self-m anagement in my community and everywhere I go. 
(P5)
The theme focused mainly on the participants' social experiences 
as persons living with diabetes mellitus having to manage the condi- It may be possible that participants such as those who experience 
tion in relation to the challenges including low income of patients stigmatization at the community and family levels may withdraw from 
and associated high cost of treatment of a chronic disease, poor ac- social interactions in the course of their illness such as seeking health 
cess to health care and resources, and scarce skilled healthcare staff. care and hence are less likely to receive the needed and expected 
It is equally important to emphasize that persons with diabetes in treatment. The felt social stigmatization lead to social isolation of the 
Ghana are stigmatized when they have severe weight loss, which is participants.
perceived to be Acquired Immune Deficiency Syndrome (AIDS) re-
lated. Additionally, persons living with diabetes incline to disregard 
health professionals' advice due to patients' poor beliefs and values 4.3  |  Subtheme 2: Impact of social isolation on 
and perceptions, which in many situations lead to pitiable patient diabetes mellitus management
consequences.
The five subthemes which emerged from the social experiences This subtheme explored the mandatory isolation that the partici-
with diabetes mellitus self- management are as follows: (1) Effects pants had to create in order to manage the diabetes. This was due 
of stigma on diabetes management. (2) Impact of social isolation on to their unwillingness to disclose their status to others with the aim 
diabetes management. (3) Financial conditions and circumstances on of circumventing other people to know that they have diabetes. It 
diabetes management. (4) Psychological/emotional effects on dia- was identified that participants had to detach themselves from col-
betes management and (5) Use of alcohol among the patients with leagues and friends at times in order to take their medications and 
diabetes mellitus. to eat at specific times. One of them narrated his story as follows:
There are times I have to isolate myself from other 
4.2  |  Subtheme 1: Effects of stigma on diabetes people, either to eat or to take my medication, to 
mellitus management make sure that I am not identified as diabetic because 
of stigmatization of having diabetes. 
This subtheme centred on social stigma which participants experi- (P10)
enced due to the changes in their physical appearance. They lost a 
statistically significant amount of weight due to the effect of the dia- Another participant also noted it this way:
betes and that made them appear typically like a client diagnosed of 
Acquired Immune Deficiency Syndrome (AIDS). The participants re- I have even stop going for reviews at the hospital 
counted their stories of been branded as having AIDS. They alleged because other people may spot me and I will feel 
 20541058, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/nop2.1825 by University of Ghana - Accra, Wiley Online Library on [15/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
KORSAH and AGYEMAN-Y­ EBOAH     |  5
embarrassed, because they will think that I have di- Similarly, another participant noted:
abetes and that is why I am frequently being seen at 
the hospital, so I have to isolate myself. I do not know what will happen to me with this con-
(P12) dition at long last as the outcome is always very bad 
based on my observations with individuals who have 
The risk of social isolation in this sense is the possibility of the par- had the condition for some time. 
ticipants to isolate themselves from individuals who may offer them (P5)
the care they deserve when the need arises. In circumstance that it 
becomes impossible for participants to isolate themselves socially to Another participant, however, noted the stress associated with the 
manage their diabetes, there is a potential of non- compliance to the condition in terms of economic challenges:
management.
As for this condition, it brings stress to the affected 
individuals because the recommended foods by the 
4.4  |  Subtheme 3: Financial conditions and health professionals are very expensive and an ordi-
circumstances on diabetes mellitus management nary person like me cannot afford. 
(P20)
The findings revealed that the financial status of the participants af-
fected diabetes mellitus self- management. The interruptions to fi- Certainly according to this patient, diabetes mellitus is not for an 
nancial position of the participants focused on limited income due to ordinary person as cost of expenditure in terms of food recommended 
financial burden on families, decrease in revenue, and amplified cost by doctors and health professionals in general is woefully exorbitant. 
of overall diabetes management. One of the patients had this to say: However, vis-à -v is with these findings, respondents were able to move 
on in the phase of some challenges associated with the influence of 
I receive meager wage from my employers, so it is social issues on diabetes self-m anagement.
very difficult for me to buy all the drugs which the 
doctors prescribe for me at the diabetes clinic. 
(P22) 4.6  |  Subtheme 5: Use of alcohol among the 
patients with diabetes mellitus
Similarly, a participant said:
In their attempts to deal with the condition, some of the patients 
I have no work doing at the moment, so I find it diffi- resorted to alcohol consumption to manage perceived stress, fear, 
cult to pay my hospital bills and to buy drugs that are apprehension and the anxiety related to the condition. Despite the 
recommended by the doctors. (P6) detrimental effects of alcohol on diabetes in the affected individu-
als, the patients opted for it as evidenced in these accounts:
Due to ill health, it is imperative that patients do have money on 
them always to be able to safeguard against every unexpected situ- I have been taking alcohol in order to forget about the 
ation. When there is no money, participants may have the tendency stress and fears about this condition. With diabetes, if 
to live in anxiety and fear due to uncertainties around the disorders one does not take to alcohol the stress alone may kill 
of diabetes. you. I do not take too much of it because at the clinic 
we were told not to take alcohol. 
(P15)
4.5  |  Subtheme 4: Psychological/emotional effects 
on diabetes mellitus self-m anagement
I know that the alcohol is not good for me, because we 
Differing from the social issues, the overall participants' responses to were told at the clinic during visits by the nurses and 
experiences living with type 2 diabetes mellitus culminated with psy- doctors not to take alcohol, however I take it to re-
chological or emotional expressions indicating fear, anxiety, stress, duce the stress and physical pain with this condition. 
apprehension and feeling about ultimate death due to organ failure. (P9)
Some emotional expressions were put forward by a participant in this 
way upon hearing the death of a colleague with diabetes mellitus: The patients appear to know complications associated with the use 
of alcohol to manage perceived stress and other problems associated 
I become fearful and I think about myself when I hear with the condition, nevertheless they resort to it, despite the health 
the death of a diabetic and ponder over who may die education given by the nurses and doctors during routine visits to the 
next time because of diabetes mellitus. (P3) clinic.
 20541058, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/nop2.1825 by University of Ghana - Accra, Wiley Online Library on [15/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
6  |    KORSAH and AGYEMAN-­YEBOAH
5  |  DISCUSSION et al., 2014) considered secondary appraisal in dealing with emo-
tional strains by means of some of the diabetes patients taking to 
The findings indicated that the participants were stigmatized by the alcohol, which is detrimental to their health, (Stuckey et al., 2014) 
pubic both at the family and community levels because the diabe- and (Chew et al., 2014) looked at the interactions between effects 
tes patients had reduced in body weight, which was perceived to of emotional strains on diabetes mellitus treatment and subsequent 
be AIDS associated. De Graft (2007) also noted that patients with quality of life (QoL) of diabetes patients.
diabetes in Ghanaian communities “face the risk of HIV/AIDS related The outcome of the current study points to the need for healthcare 
stigma” as they experienced humiliation and degradation due to re- professionals and providers in general to consider rejuvenation of mas-
duction in body weight. The concept of “social identification” related sive patient and in particular public education that weight loss in diabe-
to body size and image is associated with beliefs on thinness of the tes mellitus is not related to HIV. In this regard, the education may centre 
body weight and are interconnected with personal predicaments on the disease processes of diabetes mellitus. In this way, the public may 
and difficulties or diseases such as AIDS, which may influence the not stigmatize the patients with diabetes mellitus in which case the af-
typical body weight of people (Block et al., 2009). fected patients may avail themselves in hospitals for treatment on regu-
The study found that social isolation may have profound effect lar basis for improved patient outcomes (Browne et al., 2013). The wider 
on health seeking behaviour as patients may avoid any form of in- literature on health and disease related stigma indicates that individuals 
teractions with other people including healthcare providers who who experience stigma may decline to unveil their disease conditions 
may even offer them the needed care in critical situations. Similarly, or delay, reduce and even terminate medical treatments and manage-
(Chew et al., 2014) noted that self- isolation may lead to loneliness, ment in general, which are likely to lead to poor disease and patient 
fear of others and negative self- esteem in diabetes patients (Chew outcomes (Person et al., 2009). Other studies from high income coun-
et al., 2014; Hjelm & Beebwa, 2013). tries have noted that individuals who perceive that they are stigmatized 
Therefore, ensuring behavioural modifications and providing the because of their type 2 diabetes report of amplified emotional distress, 
appropriate and required psychosocial support during the course of reduced social support and worse glycated haemoglobin levels (Browne 
the condition may be one of the ways to reduce complications, opti- et al., 2016; Gredig & Bartelsen- Raemy, 2017; Schabert et al., 2013). As 
mize health and increase their quality of life. Other studies in Ghana part of treatment, these patients may also benefit from counselling to 
such as that by (Bosu, 2012) have also indicated that due to financial deal with the psychological distress related to unknown outcome of 
dependence on other individuals such as friends, family members and the condition. Nurses and medical doctors and other healthcare pro-
other relations, it has also resulted in desertion and social isolation viders may spend some time in their interactions with these vulnera-
in patients living with non- communicable diseases such as diabetes ble patients to offer them these forms of emotional support. Botchway 
mellitus. This phenomenon is common in Ghana as in most cases due et al. (2021) have already noted that individuals diagnosed with type 2 
to financial challenges relatives abandon their sick family members in diabetes who experience high self- stigma may have reduced social sup-
which case the sick person experiences social isolation (Bosu, 2012). port, which, in turn, may lessen their capacity for disease management 
In this study, the findings indicated that due to diabetes patients' and self-c are, therefore, such patients require emotional sustenance and 
poor financial circumstances, it affected the management of the care. Similarly, wider social networks and interactions may be beneficial 
condition. A study by (Aikins, 2006) had similar findings on the is- for individuals diagnosed with diabetes mellitus in limited resource econ-
sues of National Health Insurance Scheme (NHIS) in Ghana, but her omy, and interventions, which increase network resources for individu-
results specifically noted that treatments for individuals with diabe- als with diabetes, which may empower them as patients and ultimately 
tes mellitus becomes problematic when the patient has not regis- may facilitate diabetes control and better patient outcomes (Browne 
tered with the NHIS, in which case the burden falls on the extended et al., 2013). Equally, understanding the financial circumstances of these 
household members to bear the cost of health care of the family patients and looking for financial support for them may go a long way 
member with diabetes. A study in Ghana by (Kratzer, 2012) on struc- to ameliorate their financial stand to reduce the financial burden of dia-
tural obstacles on coping with type 1 diabetes mellitus among the betes mellitus care. There is positive association between network size 
youth and their family members showed that financial encumbrance and social support such as financial support that the patient may receive 
on them was mainly owed to, delayed monthly salary payments, high irrespective of the level of stigma (Seeman & Berkman, 1988). This is be-
cost of medications and medical appliances required for appropri- cause larger networks may include various social ties, which may offer 
ate diabetes mellitus self- management, which are external factors avenues for connections with patients and family members, and non- 
or barriers to diabetes patients' self- care (Kratzer, 2012), compared family members, friends and other distal social contacts who may serve 
with individualistic centered factors as noted in the current study. as extra sources of social support, and access to assorted resources 
The overall response to their experiences living with diabe- (Seeman & Berkman, 1988). In this vein, it may be noted that individuals 
tes mellitus included stigma, social isolation and financial burden with diabetes mellitus who are connected to various social groups may 
on patients with type 2 diabetes mellitus. In this current research obtain support with diverse health- related needs from manifold sources 
were psychological or emotional issues such as depression, stress including governmental and non- governmental organizations.
and anxiety, in which cases some of the diabetes patients began to The government may also place subsidies on their medications to 
take to alcohol to deal with the problem at hand. As much as (Chew make them affordable, this may go a long way to increase attendance 
 20541058, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/nop2.1825 by University of Ghana - Accra, Wiley Online Library on [15/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
KORSAH and AGYEMAN-Y­ EBOAH     |  7
of patients with diabetes mellitus at the diabetes clinics across the ACKNO WLED G E MENTS
country. At the hospital level, nurses, doctors, pharmacist and other The authors would like to acknowledge all the participants who 
healthcare providers may establish special fund for sick and poor pa- shared their experiences in this study.
tients including patients with diabetes mellitus to augment patients 
who may not afford payments for their medications. In this regard, FUNDING INFORMATION
funds may be solicited from benevolent and organized groups such This research received no specific funding.
as Churches, Muslim groupings, Members of Medical Doctors' Wives' 
Association, Hair Dressers and Beauticians Associations and similar CONFLIC T OF INTERE S T S TATEMENT
groupings and even from individuals who may have interest to contrib- No conflict of interest declared by the authors.
ute to the fund. There is a saying in Ghana that “Each Person is Another 
Person's Keeper” and with this spirit individuals appear to be ready to DATA AVAIL ABILIT Y S TATEMENT
support the care for others when it comes to soliciting for financial Data available on request from the authors.
assistance for people in need. These and similar interventions may go a 
long way to augment the care of patients with diabetes mellitus. RE SE ARCH E THIC S COMMIT TEE APPROVAL
Ethical and scientific approval for the study was given by the De 
Montfort University, Faculty of Health and Life Sciences Research 
5.1  |  Limitations of the study Ethics Committee (Reference Number:347). Additionally, site ap-
proval for the study was given by the Health Management Team of 
The study employed only patients with type 2 diabetes mellitus, the Holy Family Hospital, Techiman, Ghana. Similarly, permission 
newly diagnosed within a period of 3 months, excluding experi- was given by the local Diabetes Patients’ Association of Techiman to 
ences of patients with type 1 diabetes mellitus and even patients interview its members who agreed to be part of the study. Written 
with type 2 diabetes mellitus who have lived with the condition informed consent was obtained willingly from participants.
for many years. The qualitative nature of the study limits the find-
ings to the setting. As noted already, the research participants ORCID
were engaged extensively during the interviews to get detailed Joana Agyeman- Yeboah  https://orcid.org/0000-0001-6833-1701 
data and rich data from them; however, too long interaction could 
have resulted in interview fatigue of participants, which could R E FE R E N C E S
have also reduced their responses to certain pertinent questions. Aikins, A. D. G. (2006). Reframing applied disease stigma research: A mul-
In addition, back translation of interviews from English to Twi was tilevel analysis of diabetes stigma in Ghana. Journal of Community 
also done by a colleague researcher to confirm consistency and and Applied Social Psychology, 16(6), 426– 441.
accuracy as part of strategies to guarantee trustworthiness; how- Blas, E., Sommerfeld, J., & Sivasankara, K. A. (2012). Social determinants 
ever, translation as closely as possible did not occur possibly due approaches to public health: From concept to practice. World Health 
Organization.
to limited variations in the understandings of words by the lead Block, J. P., He, Y., Zaslavsky, A. M., Ding, L., & Ayanian, J. Z. (2009). 
researcher and the colleague researcher who performed the back Psychosocial stress and change in weight among US adults. 
translation. American Journal of Epidemiology, 170(2), 181–1 92.
Bosu, W. K. (2012). Acomprehensive review of the policy and program-
matic response to chronic non-c ommunicable disease in Ghana. 
Ghana Medical Journal, 46(2 Supply), 69– 78.
6  |  CONCLUSIONS Botchway, M., Davis, R. E., Merchant, A. T., Appiah, L. T., & Moore, S. 
(2021). Diabetes-r elated stigma and its influence on social net-
The study has noted some major challenges faced by patients with works, social support, and HbA1c in Ghana. Ethnicity and Disease, 
31(1), 57– 66. https://doi.org/10.18865/e d.31.1.57
type 2 diabetes mellitus including stigmatization by the pubic as- Browne, J. L., Ventura, A., Mosely, K., & Speight, J. (2013). ‘I call it the 
sociated with the body weight reduction perceived to be HIV/ blame and shame disease’: A qualitative study about perceptions 
AIDS related among others. The inclusive effects of these chal- of social stigma surrounding type 2 diabetes. BMJ Open, 3(11), 
lenges are their deleterious consequences on diabetes mellitus self- e003384. https://doi.org/10.1136/bmjope n- 2013-0 03384
Browne, J. L., Ventura, A. D., Mosely, K., & Speight, J. (2016). Measuring 
management among the affected persons. This study augments the the stigma surrounding type 2 diabetes: Development and val-
body of knowledge regarding the influence of social issues on diabe- idation of the type 2 diabetes stigma assessment scale (DSAS- 
tes mellitus self- management in the context of Ghana, which has not 2). Diabetes Care, 39(12), 2141– 2148. https://doi.org/10.2337/
been identified earlier. dc16-0 117
Centre for Disease Control and Prevention. (2021). Diabetes Basics. 
Accessed Nov 2021. Available at: https://www.cdc.gov/diabet es/
AUTHOR CONTRIBUTIONS basic s/index.html
KAK conceptualized the research, collected the data, conducted the Chew, B. H., Shariff- Ghazali, S., & Fernandez, A. (2014). Psychological 
data analysis and drafted the manuscript. JAY assisted in drafting the aspects of diabetes care: Effecting behavioral change in patients. 
manuscript and finalizing the manuscript for publication. World Journal of Diabetes, 5(6), 796–8 08.
 20541058, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/nop2.1825 by University of Ghana - Accra, Wiley Online Library on [15/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
8  |    KORSAH and AGYEMAN-­YEBOAH
Creswell, J. W., & Creswell, J. D. (2018). Research design: Quantitative, Reiners, G. M. (2012). Understanding the differences between Husserl 
qualitative and mixed method approaches (5th ed.). SAGE Publication (descriptive) and Heidegger's (interpretive) phenomenological re-
Inc. search. Journal of Nursing Care, 1, 119.
Dahlgren, G., & Whitehead, M. (1991). Policies and strategies to promote Schabert, J., Browne, J. L., Mosely, K., & Speight, J. (2013). Social stigma 
equity and health. Institute for Future Studies. in diabetes. The Patient – Patient-C entered Outcomes Research, 6(1), 
Dahlgren, G., & Whitehead, M. (1993). Tackling inequalities in health: What 1–1 0. https://doi.org/10.1007/s4027 1- 012- 0001- 0
can we learn from what has been tried? Working paper prepared for the Seeman, T. E., & Berkman, L. F. (1988). Structural characteristics of social 
King's fund international Seminaron tackling inequalities in health. The networks and their relationship with social support in the elderly: 
King's Fund. Who provides support. Social Science and Medicine, 26(7), 737–7 49. 
De Graft, A. A. (2007). Ghana's neglected chronic disease epidemic: A https://doi.org/10.1016/0277- 9536(88)90065 - 2
developmental challenge. Ghana Medical Journal, 41(4), 154– 159. Silva, J., Souza, E., Echazú Böschemeier, A. G., Costa, C., Bezerra, H. S., 
Fusch, P. I., & Ness, L. R. (2015). Are we there yet? Data saturation in & Feitosa, E. (2018). Diagnosis of diabetes mellitus and living with 
qualitative research. Qualitative Report, 20(9), 1408–1 416. a chronic condition: Participatory study. BMC Public Health, 18(1), 
Gadamer, H. G. (1997). Truth and method (2nd ed.). Continuum. 699. https://doi.org/10.1186/s1288 9-0 18- 5637- 9
Gredig, D., & Bartelsen- Raemy, A. (2017). Diabetes- related stigma af- Solar, O., & Irwin, A. (2010). A conceptual framework for action on 
fects the quality of life of people living with diabetes mellitus in the social determinants of health. In Social determinants of health 
Switzerland: Implications for healthcare providers. Health and Discussion paper 2 (policy and practice). World Health Organization.
Social Care Community, 25(5), 1620– 1633. https://doi.org/10.1111/ Stuckey, H. L. (2013). Three types of interviews: Qualitative research 
hsc.12376 Methods in social health. Journal of Social Health and Diabetes, 1(2), 
Harwood, E., Bunn, C., Caton, S., & Simmons, D. (2013). Addressing barri- 56–5 9.
ers to diabetes care and self- care in general practice: A new frame- Stuckey, H. L., Mullan- Jensen, C. B., Reach, G., Kovacs Burns, K., Piana, 
work for practice nurses. Journal of Diabetes Nursing, 17, 186–1 91. N., Vallis, M., Wens, J., Willaing, I., Skovlund, S. E., & Peyrot, M. 
Healthy people. (2020). Diabetes. Accessed Nov 2021. Available at: (2014). Personal accounts of the negative and adaptive psycho-
https://www.healt hypeo ple.gov/2020/topic s-o bjec tives/ topic/ social experiences of people with diabetes in the second diabetes 
diabetes attitudes, wishes and needs (DAWN2) study. Diabetes Care, 37, 
Hjelm, K., & Beebwa, E. (2013). The influence of beliefs about health and 2466– 2247.
illness on foot Care in Ugandan Persons with diabetic foot ulcers. Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for re-
The Open Nursing Journal, 7, 123– 132. porting qualitative research (COREQ): A 32- item checklist for in-
International Diabetes Federation (IDF). (2018). Global estimates of terviews and focus groups. International Journal for Quality in Health 
diabetes prevalence for 2017 and projections for 2045. Diabetes Care., 19(6), 349–3 57.
Research and Clinical Practice, 138, 271–2 81. Touma, C., & Pannain, S. (2011). Does lack of sleep cause diabetes? 
Jack, L., Jack, N. H., & Hayes, S. C. (2012). Social determinants of health Cleveland Clinical Journal of Medicine, 78, 549–5 58.
in minority populations: A call for multidisciplinary approaches to van Manen, M. (2014). Phenomenology of practice: Meaning- giving Methods 
eliminate diabetes-r elated health disparities. Diabetes Spectrum, in phenomenological research and writing (1st ed.). Routledge.
25(1), 9– 13. Walker, R. J., Gebregziabher, M., Martin-H arris, B., & Egede, L. E. (2014). 
Kafle, N. P. (2013). Hermeneutic phenomenological research method Relationship between social determinants of health and processes 
simplified. Bodhi, 5, 181–2 00. and out comes in adults with type 2 diabetes: Validation of a con-
Kratzer, J. (2012). Structural barriers to coping with type 1 diabetes ceptual framework. BMC Endocrine Disorders, 9(14), 82.
mellitus in Ghana: Experiences of diabetic youth and their families. Williamson, D. F., Vinicor, F., & Bowman, B. A. (2004). Centers for disease 
Ghana Medical Journal, 46(2 Supplement), 39– 45. control and prevention primary prevention working group. Primary 
Mayan, M. J. (2009). Essentials of qualitative inquiry. Left Coast Press. prevention of type 2 diabetes mellitus by lifestyle intervention: 
Person, B., Bartholomew, L. K., Gyapong, M., Addiss, D. G., & van den Implications for health policy. Annals of Internal Medicine, 140(11), 
Borne, B. (2009). Health- related stigma among women with lym- 951– 957.
phatic filariasis from The Dominican Republic and Ghana. Social World Health Organization. (2021). Diabetes. Accessed Nov 2021. 
Science and Medicine, 68(1), 30– 38. https://doi.org/10.1016/j.socsc Available at: https://www.who.int/news-r oom/fact- sheet s/detail /
imed.2008.09.040 diabetes
Pilkington, F. B., Daiski, I., Lines, E., Bryant, T., Raphael, D., Dinca- World Health Organization (WHO). (2011). Social determinants of health. 
Panaitescu, M., & Dinca- Panaitescu, S. (2011). Type 2 diabetes in World Health Organization Published 2011.
vulnerable populations: Community healthcare providers' per-
spectives of health service needs and policy implica tions. Canadian 
Journal of Diabetes, 35, 503– 511.
Raphael, D. (2004). Social determinants of health: Canadian perspectives. How to cite this article: Korsah, K. A., & Agyeman- Yeboah, J. 
CSPL.
Raphael, D., Lines, E., Bryant, T., Daiski, I., Pilkington, B., Dinca- (2023). Narratives of type 2 diabetes mellitus patients 
Panaitescu, S., & Dinca- Panaitescu, M. (2010). Type 2 diabetes: regarding the influence of social issues on diabetes self- 
Poverty, priorities and policy: The social determinants of the incidence management: Implications for patient care. Nursing Open, 00, 
and management of type 2 diabetes. York University School of Health 1–8. https://doi.org/10.1002/nop2.1825
Policy and Management.
 20541058, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/nop2.1825 by University of Ghana - Accra, Wiley Online Library on [15/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License